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DIAGNOSIS  AND  TREATMENT 

OF 

DISEASES   OF  WOMEN 


DIAGNOSIS  AND  TREATMENT 


OF 


DISEASES   OF  A\  OMEN 


BY 


HARRY  STURGEON  CROSSEN,  M.  D. 

Professor  of  Clinical  Gynecology,  Washington  University;  Gynecologist  to  Washington  University  Hospital  and 

Director  of  the  Gynecological  Clinic;  Gynecologist  to  St.  Louis  Mullanphy  Hospital,  to  Missouri  Baptist 

Sanitarium,  to  Bethesda  Hospital,  and  to  the  St.  Louis  City  Hospitals;  formerly  Superintendent 

of  the  St.  Louis  Female  Hospital;  Fellow  of  the  American  Gynecological  Society,  of  the 

American  Association  of  Obstetricians    and    Gynecologists,  and  of    the  Western 

Surgical   and  Gynecological  Association;    Ex-President   of   the  St.    Louis 

Obstetrical  and   Gynecological    Society,  Member  of    the   American 

Medical    Association,  Missouri   State   Medical    Association, 

St.  Louis  Medical  Society,  Etc. 


SECOND  EDITION,  REVISED  AND  ENLARGED 


WITH  SEVEN  HUNDRED  AND  FORTY-FOUR  ENGRAVINGS 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 

1912 


Copyright,  1910,  by  C.  V.  Mosby  Company 


n\'^ 


Press  of 

C,  V.  Mosby  ComjMny 

St.  Louis, 


TO  THE  MEMORY  OF 

DR.  HENRY  HODGEN  MUDD 

THIS  WORK  IS  RESPECTFULLY 

DEDICATED 

AS  A  SLIGHT  TOKEN  OF  APPRECIATION 

OF 

HIS  SPLENDID  PROFESSIONAL  ATTAINMENTS, 

HIS  UNSELFISH  DEVOTION  TO  THE  CAUSE  OF  MEDICAL  EDUCATION 

AND  HIS  INSPIRING  PERSONAL  FRIENDSHIP 


PREFACE  TO  THE  SECOND  EDITION. 

The  character  of  this  work  is  indicated  in  the  extract  from  the  preface  to 
the  first  edition.  My  endeavor  has  been  to  present  clearly  and  in  detail  the 
foundation  facts  and  principles  of  Gynecology — the  anatomic,  pathologic, 
diagnostic  and  therapeutic  information  underlying  successful  gynecologic 
work. 

Two  hundred  pages  of  text  and  fifty  original  illustrations  have  been  added. 
The  index,  upon  which  the  practical  usefulness  of  a  medical  book  so  largely 
depends,  has  been  greatly  amplified,  so  as  to  include  references  and  cross- 
references  to  every  diagnostic  and  therapeutic  item.  In  the  new  text  special 
attention  has  been  given  to  the  presentation  of  pelvic  inflammation  and  of 
tubal  pregnancy — two  hve  and  important  subjects,  upon  each  of  which  an 
enormous  and  chaotic  mass  of  information  has  accumulated.  To  properly 
emphasize  the  established  landmarks  and  point  out  important  features  of 
advance  work — such  was  the  task.  Disturbances  of  function  merit,  and 
have  received,  careful  and  detailed  consideration,  both  from  the  diagnostic 
and  therapeutic  standpoint.  Medico-legal  complications  are  claiming  more 
and  more  attention  each  year,  and  those  connected  with  gynecology  are 
considered  in  a  detailed  and  practical  way. 

My  thanks  are  due  to  Mr.  Thos.  Jones,  the  artist,  for  the  careful  work 
shown  in  the  new  drawings. 

I  would  appear  remiss  in  gratitude  did  I  not  express  my  appreciation  of 
the  gratifying  reception  accorded  the  first  edition  by  teachers  and  prac- 
titioners. 

H.  S.  Crossen. 
Metropolitan  Building, 

St.  Louis,  September,  1910. 


VII 


EXTEACT  ¥J{(m  PREFACE  TO  THE  FIRST  EDITION. 

This  work  is  devoted  exclusively  to  the  diagnosis  and  treatment  of  Dis- 
eases of  Women  as  those  diseases  are  met  with  in  the  office  and  at  the  bed- 
side by  the  general  practitioner.  No  space  is  given  to  other  considerations, 
except  as  necessary  to  bring  the  work  to  its  highest  usefulness  as  a  prac- 
tical guide  in  the  Hnes  indicated.  While  no  space  is  taken  up  with  detailed 
technical  descriptions  of  major  operations,  much  care  is  taken  to  set  forth 
clearly  the  differential  diagnosis  of  the  various  conditions  requiring  such 
operative  treatment,  the  kind  of  operation  called  for  by  the  particular  con- 
ditions present,  what  the  operation  is  intended  to  accomplish,  the  prepara- 
tion of  the  patient  for  operation  and  the  after-care  necessary  to  complete 
the  restoration  to  health. 

In  my  experience  as  a  consultant  and  as  a  teacher  I  find  that  the  two  prin- 
cipal stumbling-blocks  encountered  in  the  way  of  accurate  gynecologic  work 
are,  first,  the  difficulty  of  determining  exactly  the  conditions  present  in  the 
pelvis,  and,  second,  the  lack  of  a  clear  understanding  of  the  indications  gov- 
erning the  selection  of  the  particular  treatment  best  adapted  to  each  of  the 
various  classes  of  cases  under  each  disease.  Special  consideration  is  given 
to  these  important  phases  of  the  subject. 

My  endeavor  throughout  has  been  to  present  the  important  points  clearly 
and  SYSTEMATICALLY — SO  clearly  and  so  systematically  that  they  will  be 
readily  understood  and  well  retained  in  mind  for  use  at  the  bedside.  To 
this  end  much  thought  has  been  given  to  the  ARRANGEMENT  OF  THE  TEXT, 
so  as  to  show  not  only  the  facts  of  a  subject,  but  also  the  mutual  relation 
of  the  facts  and  their  bearing  and  relative  importance  in  the  diagnosis 
and  treatment.  The  necessary  facts  are  presented  clearly  and  fully,  and 
UNINCUMBERED  by  the  vast  and  confusing  mass  of  gynecological  knowledge 
with  which  the  specialist  must  deal. 

To  this  end,  likewise,  the  illustrations  have  been  most  carefully  selected, 
with  the  one  idea  of  making  clear  the  points  under  consideration.  From  the 
extensive  field  of  gynecological  literature  I  have  endeavored  to  bring  the 
BEST  illustration  available  to  elucidate  each  point.  Those  from  reference 
works  necessarily  cover  a  wide  range,  and  I  wish  here  to  express  my  hearty 
thanks  to  the  authors  and  publishers  of  the  works  so  used. 

I  have  added  over  two  hundred  and  twenty  illustrations  of  my  own.  In 
these  I  have  endeavored  particularly  to  show  the  actual  care  and  handling 
of  the  patients,  thus  bringing  to  those  who  have  not  had  the  opportunity  of 
gynecological  hospital  training  many  facts  which  can  be  satisfactorily  pre- 
sented in  no  other  way.     For  this  purpose  I  have  had  taken  over  five  hun- 

IX 


X  PREFACE 

dred  photographs.  Only  a  part  of  them,  however,  could  be  used  in  this 
work  on  account  of  limited  space.  Most  of  these  photographs  were  taken 
by  my  clinical  assistant,  Dr.  R.  E.  Wobus,  to  whose  skill  and  patience  I 
bear  appreciative  tribute. 

My  thanks  are  due  to  my  colleague,  Dr.  Henry  Schwarz,  Professor  of 
Obstetrics  in  Washington  University,  for  helpful  suggestions. 

I  wish  to  thank  Dr.  F.  J.  Taussig  and  Dr.  H.  A.  Hanser,  my  Senior  Clin- 
ical Assistants,  for  valuable  help  in  various  ways. 

To  Dr.  R.  W.  Mills,  the  artist,  I  wish  to  express  my  appreciation.  His 
painstaking  care  and  fidelity  in  representation  are  apparent  in  all  the  draw- 
ings made  by  him. 

For  engravings  of  instruments  I  am  indebted  to  Mr.  C.  W.  Alban,  instru- 
ment dealer,  of  this  city. 

The  publishers  have  aided  me  throughout  by  their  courtesy  and  cordial 
co-operation,  for  which  I  wish  to  express  my  sincere  thanks. 

H.  S.  Crossen. 

St.  Louis,  May,  1907. 


^t- 


CONTENTS. 


CHAPTER   I. 

GYNECOLOciic  Examination  Methods. 

History,  1;  Examination,  13;  Abdominal  examination,  14;  Examination  of  external 
genitals,  31;  Vaginal  examination  (digital),  39;  Vagino-abdominal  examination  (bi- 
manual), 52;  Recto-abdominal  examination,  73;  Recto-vagino-abdominal  examination,  75; 
Instrumental  examination,  77;  Pelvic  examination  under  anesthesia,  91;  Preparations 
for  gynecological  examination,  98;  Non-gynecologic  examination  methods  in  gynecological 
cases,  110. 

CHAPTER  II. 

Gynecologic  Diagnosis. 

Method  of  diagnosis,  118;  Significance  of  findings  in  abdominal  examination  (promi- 
nence, discoloration,  tension,  tenderness,  mass,  area  of  dullness),  119;  Significance  of 
findings  in  examination  of  external  genitals  (leucorrhoea,  bloody  discharge,  inflamma- 
tion, ulcer,  malformations,  lacerations,  swelling),  170;  Significance  of  findings  in  vaginal 
examination  (roughening,  tenderness,  mass,  changes  in  cervix  uteri,  mass  in  cervical 
canal),  224;  Significance  of  findings  in  vagino-abdominal  examination  (changes  in  corpus 
uteri,  mass  or  induration  in  pelvis  or  lower  abdomen),  238;  Table  for  differential  diag- 
nosis of  the  various  masses  found  in  the  bimanual  examination,  287;  Significance  of 
findings  in  speculum  examination  (conditions  of  the  vaginal  wall,  conditions  of  the  cervix 
uteri),  289;  Diagnostic  significance  of  pain  in  the  pelvis,  back  and  lower  abdomen,  297. 


CHAPTER   III. 

Gynecologic  Treatment. 

Classification  of  therapeutic  measures,  394;  Rest  (complete  rest,  partial  rest,  sexual 
rest),  306;  Applications  to  lower  abdomen  and  exterior  of  pelvis  (moist  heat,  dry  heat, 
cold,  counter-irritation),  307;  Applications  to  external  genitals,  vagina  and  cervix 
(douches,  concentrated  solutions,  powders,  tablets,  vaginal  suppositories,  tampons,  tam- 
pon-capsules, pessaries,  submucous  injection  of  substances,  local  blood-lett?ng,  curet, 
cautery,  electricity,  x-ray,  Finsen  light,  radium),  311;  Intrauterine  treatmeat  (medi- 
cated applications,  hot  water  irrigation,  curettage,  cauterization,  electricity,  cervical 
dilatation,  vacuum  treatment),  346;  Applications  within  rectum  (hot  water  irrigation,  low 
enemata,  high  enemata),  358;  Applications  to  lower  abdomen  and  interior  of  pelvis  (pel- 
vic massage,  pressure  treatment,  electricity),  359;  Applications  to  body  generally  (gen- 
eral bathing,  friction  rubbing,  general  massage,  dress  corrections),  365;  Postural  methods 
and  exercise  (knee-chest  posture,  Trendelenburg  posture,  general  exercise,  special  exer- 
cise), 367;  Internal  treatment  (medicines,  diet,  psychotherapy),  370;  Operations,  373. 

XI 


XII  CONTENTS 


CHAPTER  IV. 

Diseases  of  Exterxat,  Genitals  and  Vagina. 

Points  in  anatomy,  375;  Classification  of  diseases,  384;  Gonorrhoea,  384;  Other  in- 
flammatory diseases  of  vulva  (simple  vulvitis,  follicular  vulvitis,  erysipelas,  cellulitis, 
gangrene,  diphtheria,  eczema,  intertrigo,  herpes,  prurigo,  parasitic  diseases),  402;  Other 
inflammatory  diseases  of  the  vagina  (simple  vaginitis,  parasitic  vaginitis,  diphtheritic 
vaginitis,  emphysematous  vaginitis,  adhesive  vaginitis),  413;  Ulcers  of  vulva  (simple 
ulcer,  chancroid,  syphilis,  tuberculosis,  malignant  disease,  ulcus  rodens  vulvae),  419; 
Urethral  affections  (urethritis,  peri-urethral  abscess,  prolapse  of  urethral  mucosa,  ure- 
thral caruncle),  438;  Vulvo-vaginal  gland  affections  (inflammation,  abscess,  sinus,  cyst), 
441;  Non-malignant  growths  and  swellings  (condylomata,  cysts,  fibromata,  lipomata, 
stasis  hypertrophy,  elephantiasis,  pudendal  hernia,  pudendal  hydrocele,  hematoma,  vari- 
cose veins),  444;  Injuries  of  vulva  and  vagina,  457;  Miscellaneous  affections  (kraurosis 
vulvae,  pruritis  vulvae,  hyperesthesia  of  vaginal  entrance,  adhesions  of  prepuce  and 
labia),  458. 

[The  more  pronounced  malformations  are  considered  in  Chapter  XIII.] 

CHAPTER  V. 

Lacerations  and  Fistulae  of  Pelvic  Floor.  Perineum,  Extern.\l  Genitals  and 

Vagina. 

Points  in  Anatomy,  467;  Laceration  of  pelvic  floor  and  perineum,  473;  Cystocele  and 
rectocele,  504;  Recto-vaginal  fistula,  506;  Vesico-vaginal  fistula,  510;  Destruction  of 
urethra,  519. 

CHAPTER    VI. 

Inflammatory    and  NrTRiTi\-E;   Diseases   of  Uterus. 

Points  in  anatomy  and  physiology,  520;  Pathological  changes  resulting  from  inflam- 
matory and  nutritive  disturbances,  536;  Classification  of  diseases,  537;  Localization  of 
diseases,  538;  Affections  of  the  cervix  uteri  (erosion,  ulcer,  endocervicitis,  hypertrophy 
of  cervix,  polypi  of  cervix,  laceration  of  cervix),  539;  Affections  of  the  corpus  uteri 
(acute  metritis  and  endometritis,  chronic  infected  endometritis,  chronic  simple  endome- 
tritis, subinvolution,  hyperinvolution,  sclerosis,  tuberculosis,  syphilis,  echinococcus  dis- 
ease), 562. 

CHAPTER  VII. 

Displace:\ient  of  the  Uterus. 

Points  in  anatomy,  595;  Backward  displacement  of  uterus  (retroversion,  retroflexion), 
597;  Prolapse  of  the  uterus,  619;  Forward  displacement  of  uterus  (anteflexion,  ante- 
version),  624;  Lateral  displacement  of  uterus,  f)24;    Inversion  of  uterus,  624. 

CHAPTER  VIII. 

FiBBOMYO.MA     OF    THE     UtERUS. 

Points  in  pathology,  625;  Symptoms,  631;  Examination  signs  and  differential  diag- 
nosis, 634;  Palliative  treatment,  637;  Curative  treatment,  641;  Choice  of  treatment,  642; 
Pregnancy  and  fibroid,  656;  Lipoma  of  uterus,  658. 


CONTENTS  XIII 

CHAPTER  IX. 

M.\i.u;n.\nt  Diseases  of  the  Uteri's. 

Carcinoma  of  cervix,  659;  Pathology,  659;  Symptoms  and  diagnosis,  667;  Choice  of 
treatment,  673;  Curative  treatment,  675;  Palliative  treatment,  683;  Carcinoma  of  corpus 
uteri,  686;  Sarcoma  of  uterus,  689. 

CHAPTER  X. 

Pki.vic  Ixfla:mmatiox. 

■ "      Podnts  in  anatomy  of  Fallopian  tubes,  pelvic  peritoneum  and  pelvic  connective  tissue, 
'691;    Acute  pelvic  inflammation    (salpingitis,  oophoritis,   pelvic   peritonitis,   pelvic  cellu- 
■  litisn  698;  Chronic  pelvic  inflammation   (salpingitis,  oophoritis,  pelvic  peritonitis,  pelvic 
cellulitis),  728. 

At  CHAPTER  XI. 

Other  Affections  of  Faixopiax  Tubes,  Peritoneum  and  Connective  Tissue. 

Pelvic  tuberculosis,  760;  Tubal  pregnancy,  764;  Pelvic  hemorrhage,  793;  Fulminating 
pelvic  edema,  795;  Tumors  of  Fallopian  tubes,  796;  Varicose  veins  of  broad  ligament,  797; 
Echinococcus  disease  of  pelvis,  798;  Pseudo-tuberculosis  of  pelvis,  798. 

CHAPTER  XII. 

Tumors  of  the  Ovary  and  the  Parovarium. 

Points  in  anatomy  and  physiology,  799 ;  Classification  of  tumors  of  ovary,  809 ;  Cystic 
tumors  of  ovary,  810 ;  Solid  tumors  of  ovary,  831 ;  Tumors  of  parovarium  (broad  ligament 
tumors),  832. 

CHAPTER  XIII. 

Malformations. 

Points  in  development,  836;  Anomalies  of  development,  840;  Imperforate  hymen,  841; 
Atresia  of  vagina,  842;  Double  vagina,  843;  Malformations  of  uterus,  844;  Pseudo-her- 
maphroditism,  845. 

CHAPTER  XIV. 

Disturbances  of  Function. 

Disturbances  of  menstruation  (normal  menstruation,  absence  of  menstruation,  scanty 
menstruation,  excessive  menstruation,  painful  menstruation,  irregular  menstruation,  pre- 
cocious menstruation,  vicarious  menstruation),  847;  Disturbances  of  sexual  intercourse 
(dyspareunia,  sexual  impotence),  892;  Disturbance  of  childbearing  (sterility),  895;  Geni- 
tal discharge  (leucorrhoea,  bloody  discharge),  900. 

CHAPTER  XV. 

Invasion   of  the   Peritoneal  Cavity  for  the   Treatment  of   Gynecological   Diseases. 

Abdominal  section  (indications,  contraindications,  preparations,  brief  explanation  of 
regular  steps  and  special  points),  909;  Vaginal  section  (indications,  contra-indications, 
preparations,  steps),  942;  Conservative  surgery  of  ovaries,  tubes  and  uterus,  945. 


XIV  CONTENTS 

CHAPTER  XVI. 

After-Tkeatmext  of   Operative   Cases. 

Abdominal  section  (regular  after-treatment,  drainage  cases,  uterine  replacement  cases, 
severe  shock,  internal  hemorrhage,  persistent  vomiting,  acute  dilatation  of  stomach,  kid- 
ney insufficiency,  constipation  and  intestinal  paralysis,  intestinal  obstruction,  peritonitis, 
suppuration  in  wound,  phlebitis,  pain  during  convalescence,  subsequent  disturbances), 
948;  Vaginal  section,  965;  Pelvic  abscess,  968;  Perineorrhaphy,  968;  Trachelorrhaphy,  968; 
Curetment,  968;  Extra-peritoneal  shortening  of  round  ligaments,  968. 

CHAPTER  XVII. 

Medico-Legal  Points  ix  Gyxecology. 

Rape,  968;  Foreign  bodies  left  in  abdomen,  979;  Transmission  of  venereal  diseases, 
985;  Testimony  in  coroner's  cases,  malpractice  suits  and  criminal  trials,  985. 

APPENDIX. 

Formulae. 

Cathartics,  987;  Emmenagogues,  987;  Sedatives,  987;  Stimulants,  988;  Styptics,  988; 
Tonics,  989;  Ointments,  989;  Powders,  990;  Solutions,  990;  Suppositories,  991;  Tablets, 
991. 


ILLTTSTKATIONS. 


Relations  of  the  Pelvic  Oroaxs. 

FIG.  PACE 

1  Antero-posterior  section  of  pelvis 1 

2  Contour  and  measurements  of  two  models 2 

3  Antero-posterior  section,  with  intestines  out      .          3 

4  Posterior  view  of  pelvic  organs 4 

5  Anterior  view  of  pelvic  organs 4 

6  Relation  of  pelvic  organs  to  external  surface 5  _ 

Gynecologic  Examixatiox  Methods. 
The  History. 

7  Indicating  general  pelvic  distress 6 

8  Backache  from  pelvic  disease 7 

9  Sacral  pain  from  pelvic  disease 7 

10  Pain  in  right  tubo-ovarian  region 8 

11  Pain  in  appendix  region 8 

12  Pain  in  stomach  region 9 

13  Pain  in  liver   region 9 

14  Pain   in   right  kidney   region,    laterally 9 

1.5  Pain  in   right  kidney  region,    posteriorly 9 

16  Gynecologic   history  card,   face 11 

17  Gynecologic  history  card,   reverse 11 

Abdominal  Examination. 

18  Patient  arranged  for  abdominal  examination 13 

19  Profile  of  normal  abdomen 14 

20  Surface  of  normal  abdomen 15 

21  Abdominal   surface   with  landmarks 16 

22  Abdominal   surface  with    landmarks 17 

23  Palpation  of  the  abdomen,  first  step 18 

24  Palpation   of  the   abdomen,   second   step 18 

25  Palpation    with    both    hands 18 

26  Deep   palpation   with    both   hands 18 

27  Abdominal  surface  divided  into  quadrants 19 

28  Usual  anatomical   division  of  abdominal   surface 20 

29  Division  of  abdominal  surface  with  circle 21 

30  Regions,  by  division  with  circle 22 

31  Various   areas  of   significant  point-tenderness 23 

32  Point  for  kidney  tenderness,   laterally 24 

33  Point  for  kidney  tenderness,   posteriorly 24 

XV 


XVI  ILLUSTRATIONS 

FIG.  PAGE 

34  Relation  of  kidney  to  last  rib ,     ,     , 24 

35  Trying  for  a  fluid  wave   across   abdomen 24 

36  Differentiating  a   fat  wave   from  a  fluid   wave 26 

37  Attempting  to  displace  a  mass  upward 27 

38  Ordinary  percussion   of   abdomen 29 

39  Deep  percussion  of  abdomen 29 

40  Lines  for  mensuration  of  abdomen 30 

Examination  of  External  Genitals. 

41  Patient  arranged  for  examination  of  external  genitals  and  adjacent  structures  32 

42  Normal  external    genitals       33 

43  Normal   external  genitals,  multipara 34 

44  Examining  upper  part  of  vestibule 35 

45  Examining  lower  part  of  vestibule 35 

46  Pressing  pus  from  urethra 36 

47  Appearance  of  pus  about  urethral   opening 36 

48  Drop  of  pus  pressed   from   Skene's   gland 36 

49  Vulvo-vaginal  gland 36 

50  Appearance  of  pus  about  vulvo-vaginal  gland 37 

51  Palpating  vulvo-vaginal  gland 37 

Vaginal  Examination    'Digital  Examination). 

52  Position  of  fingers  for  vaginal  examination 40 

53  Hand  gloved,  ready  for  examination 40 

54  Position  of  thumb  and  outside  fingers 41 

55  Bony  arch  above  vaginal  opening 43 

56  Testing  the  pelvic  floor  with  one  finger 45 

57  Testing  the  pelvic  floor  with  two  fingers 46 

58  Showing  separation  of  examining  fingers 46 

59  Another  method  of  testing  pelvic  fioor 47 

60  Palpating  rectum  through  vaginal  wall 48 

61  Method  of  everting  anal  tissues 48 

62  Showing  possible  eversion  in  some  cases 49 

Tagino-Ahdominal   Examination    (Bimanual   Examination). 

63  Bimanual  examination,  outside  fingers  folded  in  palm 53 

64  Bimanual  examination,  outside  fingers  extended  in  gluteal  crease 53 

65  Palpating  body  of  uterus 54 

66  Depressing  abdominal  wall  too  close  to  pubes,  sectional  view 54 

67  Depressing  wall  too  close  to  pubes,  outside  view 55 

68  Depressing  wall  at  right  height 55 

69  Bimanual  examination,  body  of  uterus  not  found  in  front 56 

70  Retroverted  uterus  found  behind 56 

71  Retroflexed  uterus  found  behind 56 

72  Palpating  sides  of  uterus  with  one  finger ■  58 

73  Palpating  sides  of  uterus  with  two  fingers 58 

74  Drawing  uterus  down,  to  aid  in  examination 59 

75  Invagination  of  perineum,  elbow  on  knee 60 

76  Same  as  Fig.  75  in  bimanual  examination 61 

77  Invagination  of  perineum,  elbow  against  iliac  crest 62 

78  Palpation  of  lateral  regions,  first  step •    •  62 


\ 

ILLUSTRATIONS  XVII 

FIG.  PAGE 

79  Palpation  of  lateral  regions,  second  Btep 62 

80  Showing  marked  depression  of  abdominal  wall  in  pelvic  palr)ation 63 

81  Palpating  the  tubo  ovarian  region 65 

82  Palpating  the  left  tubo-ovarian   region 65 

83  Palpating  the  right  tubo-ovarian  region 66 

84  Determining  attachment  of  mass  to  uterus 67 

85  Determining  attachment  to  posterior  part  of  uterus 68 

86  Palpating  region  of  right  ureter 68 

87  Location  of  pelvic  nerve  i-oots 69 

88  Palpating  pelvic  nerve  roots 69 

89  Method  of  palpating  coccyx 76 

Instrumental  Examination. 

90  Instruments  for  regular  speculum  examination 78 

91  Bivalve  speculum  in  place 79 

92  Introducing  the  bivalve  speculum,  first  step 80 

93  Speculum  carried  half  way  in 81 

94  Speculum  turned  and  carried  all  the  way  in 81 

95  Bivalve  speculum  changed  to  Sims'  speculum , ,  84 

96  Patient  in  Sims'  posture 85 

97  View  from  above,  showing  Sims'  posture 85 

98  Method  of  introducing    Sims'    speculum 86 

99  Method  of  holding  Sims'  speculum 86 

100  Cervix  uteri  brought  into  view 87 

101  Instruments  for  exploration  of  interior  of  uterus 88 

102  Recto-abdominal  palpation 93 

103  Method  of  palpating  the  pedicle  of  a  tumor 94 

104  Recto-vagino-abdominal  palpation       95 

105  Exploration  of  interior  of  uterus  with  finger     .     .     .     .     • 97 

Preparation  for  Gynecologic  Examination. 

106  Kitchen  table  arranged  for  gynecologic  examination 98 

107  Simple  instrument  boiler 101 

108  Small  instrument  and  dressing  sterilizer 101 

109  Articles  needed  for  preparing  for  gynecologic  examination 102 

110  Use  of  gloves  and  drop-bottle  for  liquid  soap 102 

111  Wall  fixture  for  liquid  soap , 103 

112  Patient  arranged  in  bed  for  abdominal  examination      .     .     .     „     , 104 

113  Patient  arranged  in  bed  for  vaginal    examination 105 

114  Patient  arranged  in  bed  for  bimanual  examination 106 

115  Showing  position  of  arms  for  accurate  deep  pelvic  palpation 107 

116  Regular  cross-bed  position 108 

117  Partial   cross-bed   position 109 


Gyxecologic  Diag>'osis. 
Prominence  of  Alidomen. 

118  Obesity,  patient  lying  on  back 119 

119  Testing  thickness  of  abdominal  wall,  first  step 120 

120  Testing  thickness  of  abdominal  wall,  second  step 120 


XVIII  ILLUSTRA.TIONS 

FIG.                                                                                                                                                                                     .  PAGE 

121  Obesity,  patient  standing 121 

122  Obesity  mistaken  for  ovarian  tumor 121 

123  Obesity  mistaken  for  pregnancy 121 

124  Tumor  of  abdominal  wall' 122 

125  Small  umbilical  hernia 122 

126  Large  umbilical  tiernia 123 

127  Contour  of  relaxed  abdominal  wall,  patient  recumbent 123 

128  Same  as  Fig.  127,  patient  standing 123 

129  Space  between  separated  recti  muscles 124 

130  Projection  of  abdominal  contents  between  separated  recti  muscles 124 

131  Depression  of  wall  between  separated  recti 125 

132  Tympanites  mistaken  for  pregnancy 126 

133  Moderate  ascites  in  relaxed  abdomen 126 

134  Marked  ascites,  showing  contour 127 

135  Extreme  ascites,  showing  contour 127 

136  Extreme  ascites,  with  pyramidal   contour 128 

137  Extreme  ascites,  with  different  contour 128 

138  Extreme  ascites,  view  from  in  front 129 

139  Contour  of  abdomen  in  pregnancy 130 

140  Contour  of  abdomen  in  case  of  distended  bladder 130 

141  Case  of  ruptured  bladder,   section 130 

142  Contour  of  abdomen  in  case  of  large  pelvic  cyst 131 

143  Contour  of  abdomen  in  case  of  large  solid  tumor 131 

144  Case  of  large  cystic  tumor 132 

145  Case  of  exstrophy  of  bladder 132 

146  Contour  of  abdomen  in  case  of  retroperitoneal  tumor 133 

Tenderness  or  Mass  in  Abdomen. 

147  Right  lower  abdomen,  important  areas  indicated 135 

148  Point  to  seek  for  right  tubo-ovarian  tenderness 136 

149  Palpating  for  right  tubo-ovarian  tenderness  or  mass 136 

150  Point  to  seek  for  appendix  tenderness 136 

151  Palpating  for  tenderness  or  mass  in  appendix  region 136 

152  Palpating  for  the  appendix 137 

153  Another  method  of  palpating  for  the  appendix 137 

154  Point  to  seek  for  tenderness  of  right  ureter 13S 

155  Palpating  for  tenderness  or  thickening  about  right  ureter 13? 

156  Left  lower  abdomen,  important  areas  indicated 13& 

157  Palpating  for  tenderness  or  mass  in  left  tubo-ovarian  region 140 

158  Point  to  seek  for  tenderness  or  infiltration  about  left  ureter 140 

159  Central  lower  abdomen,  showing  the  organs  commonly  affected 141 

160  Point  to  seek  for  tenderness  about  uterus 142 

161  Point  to  palpate  for  bladder  tenderness 143 

162  Region  for  right  kidney  tenderness  in  front 144 

163  Region  for  right  kidney  tenderness  at  side 144 

164  Region  for  right  kidney  tenderness  behind       144 

165  Region  for  left  kidney  tenderness 145 

166  Palpating  for  mass  in  left  kidney  region 145 

167  Right  upper  abdomen,  important  organs  indicated 146 

168  Site  for  gall-bladder  tenderness  or  mass 147 

169  Palpating  for  liver  tenderness 147 

170  Left  upper  abdomen 148 


ILLUSTRATIONS  XIX 

Fia  PACE 

171  Regions  for  splenic  tenderness  or  mass I49 

172  Central  upper  abdomen 150 

173  Region  for  tenderness  or  mass  from  disease  of  stomach  or  pancreas     ....  151 

174  Site  for  tenderness  about  left  lobe  of  liver 151 

175  Indicating  pain  under  left  shoulder  blade,  common  in  stomach  disease     ...  151 

176  Indicating  pain  under  right  shoulder  blade,  common  in  liver  disease     ....  151 

177  Central  abdomen    (umbilical  region) 152 

178  Palpating  for  tenderness  or  mass  in  the  umbilical  region 153 

179  Showing  the  direction  of  growth  of  various  pelvic  and  abdominal  tumors     .     .  153 

Area  of  Dullness  in  Abdomen. 

180  Indicating  area  of  dullness  from  distended   bladder 154 

181  Indicating  area  of  dullness  from  enlarged  uterus 154 

182  Indicating  area  of  dullness  from  very  large  central  pelvic  mass 155 

183  Indicating  dullness  from  enlarged   liver 156 

184  Indicating  dullness  from  enlarged   spleen 156 

185  Area  of  dullness  in  moderate  ascites,  patient  on  back 157 

186  Relation  of  fluid  to  intestines  in  ascites 157 

187  Relation  of  mass  to  intestines  in  tumor 157 

188  Showing  gravitation  of  ascitic  fluid  to  lower  side 157 

189  Indicating  dullness  in  moderate  ascites,  patient  on  side 158 

190  Indicating  dullness  in  moderate  ascites,  patient  standing 158 

191  Area  of  resonance  in  case  of  extreme  ascites,  patient  on  back 159 

192  Same  as  Fig.  191,  patient  standing 160 

193  Same  as  Fig.  191,  the  two  resonant  areas  contrasted 161 

194  Dullness  in  case  of  ascites  and  tumor,  patient  on  back 162 

195  Same  as  Fig.  194,  patient   standing       163 

196  Same  as  Fig.  194,  two  areas   of  dullness   contrasted 164 

197  Indicating  dullness  in  large  tubo-ovarian   mass         16-4 

198  Indicating  dullness  in  large  appendiceal  mass 164 

199  Indicating  irregularity  of  dullness  from  uterine  fibromyoma     .     , 165 

200  Indicating  regularity  of  dullness  from  large  ovarian  cyst 165 

201  Area  of  dullness  in  case  of  retroperitoneal  growth 166 

202  Indicating  dullness  in  kidney  tumor,  without  inflation  of  colon     ......  166 

203  Same  as  Fig.  202,  with   inflation  of  colon 167 

204  Kidney  tumor  removed  in  case  of  Fig.  202 167 

205  Case   of  perirenal  lipoma,   section 168 

206  Same  as  Fig.  205,  from  in  front 169 

Changes  About  External  Genitals. 

207  External  genitals  of  virgin , 170 

208  External  genitals,    diagrammatic        170 

209  Various  forms  of  hymen 171 

210  External  genitals  of  married  woman 171 

211  External  genitals  of   multipara 172 

212  Same  as  Fig.  211,  prepared  for  operation 173 

213  Same  as  Fig.  211,  closer   view       174 

214  Same  as  Fig.  211,  still  closer  view,  with  operating  speculum  in  place     ....  175 

215  External  genitals  with  some  perineal  laceration 176 

216  Follicular  vulvitis 180 

217  Kraurosis  vulvae 181 

218  Chancroidal  ulcers  of  vulva 181 


XX  ILLUSTRATIONS 

FIG.  PAGE 

219  Tubercular  ulcer  of  vulva 182 

220  Epithelioma  of  right  labium 183 

221  Beginning  epithelioma   of  labium •  .     .  183 

222  Epithelioma  of   clitoris 183 

223  Case   of   adherent  prepuce 184 

224  Same  as  Fig.  223,  after  treatment 184 

225  Adherent  labia  minora 184 

226  Imperforate  hymen 184 

227  Hematocolpos 185 

228  Distention  of  uterus  and  tubes  from  imperforate  hymen 185 

229  External  genitals  in  case  of  absence  of  vagina 185 

230  Double  vagina , 186 

231  Same  as  Fig.  230,  each  vagina  spread  open 186 

232  Complete  laceration  of  perineum 186 

233  Complete  laceration  of  perineum 187 

234  Separation  of  sphincter  ends  in  old  complete  laceration 187 

235  Central  perforation  of  perineum  by  child's  head 188 

236  Laceration  of  hymen  from  rape 188 

237  Complete  laceration  of  perineum  from  rape 188 

238  Laceration  of  perineum,  with  resulting  fistula,  from  violent  coitus 189 

239  Old  laceration  of  pelvic  floor  from  labor 189 

240  Moderate  cystocele  and  rectocele 190 

241  Same  as  Fig.  240,  showing  section .  190 

242  Large  cystocele 191 

243  Testing  for  cystocele  with  sound  in  bladder 192 

244  Small  rectocele 192 

245  Large  rectocele 193 

246,  247     Differentiating  between  rectocele  and  colpocele 193 

248  Hematoma  of  vulva 194 

249  Stasis-hypertrophy  of  labia  minora 194 

250  Stasis-hypertrophy  of  vulva 195 

251  Stasis-hypertrophy  of  vulva 195 

252  Stasis-hypertrophy  and  edema 196 

253  Marked  stasis-hypertrophy 196 

254  Stasis-hypertrophy  with  causative  ulceration 196 

255  Elephantiasis  of  vulva 196 

256  Varicose  veins  of  vulva 197 

257  Scattered  condylomata  of  vulva 197 

258  Small  masses  of  condylomata 198 

259  Large  masses  of  condylomata 198 

260  Vulva  covered  with  massed  condylomata 198 

261  Syphilitic  condylomata  about  vulva 199 

262  Syphilitic  condylomata,  flat  variety 199 

263  Syphilitic  condylomata,  pointed  variety 200 

264  Abscess  of  vulvo-vaginal  gland 201 

265  Abscess  of  vulvo-vaginal  gland 202 

266  Cyst  of  vulvo-vaginal  gland 202 

267  Hypertrophy  of  labia  minora 203 

268  Enormous  hypertrophy  of  labia  minora  (Hottentot  apron) 203 

269  Hypertrophy  of  clitoris 204 

270  Carcinoma  of  labium,  beginning 204 

271  Carcinoma  of  labium,  later  stage 205 

272  Carcinoma  of  labium,  still  later  stage -   .     .  205 


ILLUSTKATIONS  XXI 

FIG.  PAGE 

273  Carcinoma  of  vulvo-vaginal  sland 206 

274  Sarcoma  of  labium 207 

275  Small  fibroma  of  labium 207 

276  Large  fibroma  of  labium 207 

277  Small  cysts  of  labium 208 

278  Large  cyst  of  labium 209 

279  Large  cyst  of  labium 209 

280  Cyst   of    clitoris 209 

281  Inguinal  liernia,   becoming  pu;lendal 210 

282  Vaginal  hernia,  becoming  puilendal 210 

283  Prolapse  of  urethral  mucosa 211 

284  Urethral  caruncle 211 

285  Suburethral  abscess 212 

286  Exploring   suburethral    abscess-sinus 213 

287  Prolapse  of  uterus,  showing  various  stages 213 

288  Prolapse  of  uterus,  cervix  at  vestibule 214 

289  Prolapse  of  uterus,  uterus  lialf  out 215 

290  Complete  prolapse  of  uterus 216 

291  Prolapse  of  uterus,  bladder  not  prolapsed 216 

292  Prolapse  of  uterus  and  bladder 217 

293  Testing  for  prolapse  of  bladder  with  sound 217 

294  Prolapse  of  uterus  in  nullipara 218 

295  Prolapse  of  uterus  in  virgin 218 

296  Bimanual  examination  in  prolapsus  uteri 219 

297  Three  portions  of  the  cervix  uteri 219 

298  Hypertrophy  of  infravaginal  portion  of  cervix,  diagrammatic 219 

299  Case  of  hypertrophy  of  infravaginal  portion  of  cervix 220 

300  Hypertrophy  of  supravaginal  portion  of  cervix 220 

301  Hypertrophy  of  intermediate  portion  of  cervix 220 

302  Peculiar  hypertrophy  of  cervix 220 

303  Pediculated  fibroid  tumor  of  ut<irus 221 

304  Complete  inversion  of  uterus,  with  placenta  attached 222 

305  Small  cyst  of  vaginal  wall 222 

306  Larger  cyst  of  vaginal  wall 223 

Changes  Found  by  Vaginal  Examination. 

307  Small  uterine  fibroid  projecting  into  vagina 226 

308  Large  uterine  fibroid  projecting  into  vagina 226 

309  Differentiating  a  pediculated  fibroid  with  sound 226 

310  Sarcoma  of  uterus  projecting  into  vagina 227 

311  Grape-like  sarcoma  of  cervix,  forming  mass  in  vagina 227 

312  Inverted  uterus,  forming  mass  in  vagina 228 

313-316     Differentiating  inversion  from  fibroid 228 

317-321     Differentiating  inversion  from  fibroid 229 

322,  323     Diagnosis  of  inversion  of  uterus 229 

324  Sounding  uterus  in  diagnosis  of  inversion 230 

325  Partial  inversion  caused  by  fibroid 230 

326  Small  cysts  of  vaginal  wall 230 

327  Anterior  vaginal  hernia 230 

328,  329     Relation  of  cervix  uteri  to  examining  finger 232 

330  Antefiexion  of  cervix  uteri 232 

331  Eversion  of  cervical  mucosa  from  inflammation 233 


XXII  ILLUSTRATIONS 

FIG.  PAGE 

332-337     Lacerations  of  cervix  uteri 234 

338  Softening  of  cervix  in  early  pregnancy 23-5 

339  Section  of  cervix  in  late  pregnancy,  showing  cervix  still  of  full  length     .     .     .  23.5 

340  Carcinomatous  nodule  in  cervix 235 

341  Nodule  due  to  cyst  of  cervix 236 

342  Polypi  of  cervix 237 

Changes   in   Corpus  Uteri. 

343  Retrodisplacement  of  uterus,  showing  first,  second  and  third  degrees     ....  239 

344  rterus  displaced  by  full  bladder 239 

345  Uterus  displaced  by  inflammatory  mass 239 

346  Uterus  displaced  by  tumor 240 

347  Uterus  displaced  by  adhesions 240 

348  Uterus  enlarged  from  early  pregnancy 241 

349  Early  pregnancy  with  slight  retrodisplacement 242 

350  Early  pregnancy  with  marked  retrodisplacement 242 

351  Pregnant  uterus  sectioned,  showing  cause  of  Hegar's  sign 243 

352  Explaining  Hegar's  sign 243 

353  Palpating  for  Hegar's  sign,  uterus  in  front 243 

354  Palpating  for  Hegar's  sign,  uterus  behind 243 

355  Small  fibroid  nodules  in  uterus ^ 244 

356  Larger  fibroid  nodules  in  uterus 244 

357  Fibroid  nodules  in  uterus 244 

358  Single  fibroid  causing  slight  enlargement  of  corpus  uteri 245 

359  Slight  enlargement  of  corpus  uteri  from  carcinoma  of  endometrium     ....  245 

360  Slight  enlargement  of  corpus  uteri  from  sarcoma 246 

361  Lipoma  of  uterine  wall 247 

362  Tuberculosis  of  uterus 248 

363  Enlargement  of  corpus  uteri  from  pregnancy,  about  four  months 248 

364  Pregnancy  of  about  five  months 249 

365  Pregnancy  at  full  term 249 

366  Comparison  of  pregnant  with  non-pregnant  uterus 249 

367  Height  of  fundus  uteri  at  different  weeks  of  pregnancy 250 

368-370     Irregular  shapes  that  pregnant  uteri  may  present 250 

371  Interstitial  pregnancy 251 

372  Pregnancy  in  right  half  of  septate  uterus 251 

373  Uterus  enlarged  by  large  single  soft  fibroid 252 

374  Uterus  symmetrically  enlarged  by  fibroids 253 

375  Subperitoneal   fibroids 253 

376  Single  large  fibroid  choking  pelvis 254 

377  Large  fibroids  filling  pelvis  and  lower  abdomen 254 

378  Uterus  enlarged  from  carcinoma 254 

379  Large  fibroid  and  early  pregnancy 254 

380  Small  fibroid  and  late  pregnancy 255 

381  Uterus  distended  with  menstrual  blood 255 

382  Uterus  enlarged  by  collection  of  pus  and  gas 255 

.     Muss  in  Pelvis  or  Loaer  Abdomen. 

383  Three  areas  in  the  pelvis 257 

384  Parametrial  inflammation  contrasted  with  ischio-re(  tal  inflammation     ....  257 

385  Mass  in  right  ureter 259 


ILLUSTRATIONS  XXIII 

FIG.  PAGE 

386  Abscess  in  broad  ligament 260 

387  Hematoma  in  broad  ligament 260 

388  Cyst  in  broad  ligament 260 

389  Ovarian  cyst  beside  uterus 261 

390  Hematometra  in  rudimentary  horn  of  uterus 261 

391  Thickened  tube  and  ovary  prolapsed  into  cul-de-sac 262 

392  Fibroid  back  of  cervix  uteri 262 

393  Fibroid  above   retrodisplaced    uterus 262 

394  Abscess  behind  uterus 264 

395  Blood-mass   behind   uterus 264 

396  Ovarian  cyst  behind  uterus 265 

397  Testing  mobility  of  mass  behind  uterus 265 

398  Fibroid  in  front  of  uterus 266 

399  Bladder  tiimor  in  front  of  uterus 266 

400  Tuberculosis  of  bladder,  forming  mass  in  front  of  uterus 267 

401  Inflammatory  exudate  filling  pelvis 267 

402  Inflammatory  roof  above  vagina 268 

403  Pelvis  filled  with  bony  tumor 268 

404  Pelvis  filled  with  ovarian  cyst  and  pregnant  uterus 269 

405  Salpingitis  nodosa 269 

406  Thrombosis  of  veins  of  broad  ligament 270 

407  Tubal  pregnancy  in  right  side 270 

408  Pregnancy  in  rudimentary  horn  of  uterus 271 

409  Pregnancy  in  rudimentary  horn  of  uterus 271 

410  Various  locations  of  appendix 272 

411  Various  locations  of  caecum 272 

412  Displaced  right  kidney 273 

413  Palpation  of  movable  kidney,  first  step 274 

414  Palpation  of  movable  kidney,  second  step 274 

415  Double  pyosalpinx  with  adhesions 276 

416  Double  pyosalpinx  without  adhesions 277 

417  Pyosalpinx  with  extensive  adhesions 277 

418  Right  hydrosalpinx 278 

419  Small  ovarian  cyst  of  right  side 278 

420  Graafian  follicle  cysts  which  have  become  intraligamentary '.  279 

421  Large  pelvic  mass  formed  by  uterine  fibroids  and  carcinoma 282 

422  Extrauterine  pregnancy,  advanced 283 

423  Extrauterine  pregnancy  with  litliopedion 283 

424  Lithopedion  removed 283 

425  Left  kidney  displaced  into  pelvis 284 

426  Large    cystic    fibroid 284 

427  Ovarian  cyst  with  long  pedicle 285 

428  Large   dermoid  cyst 286 

429  Ascites  and  uterine  fibroid 286 

Chavf/es  Seen  Hirou(jh  SpeculiuJi. 

430  Primary  cancer  of  vaginal  wall 289 

431  Secondary  cancer  of  vaginal  wall 290 

432-434     Varieties  of  normal  cervix .          .  291 

435  Senile  cervix 291 

436  Discharge  from  cervix '     .     .  291 

437  Laceration  and  erosion  of  cervix 291 


XXIV  ILLUSTRATIONS 

FIG.  PAGE 

438  Erosion  and  cysts  of  cervix 291 

439  Lacerations  and  erosions  of  cervix 292 

440  Lacerations  and  erosions  of  cervix 293 

441,  442     Testing  for  laceration  of  cervix 294 

443  Beginning  epithelioma  of  cervix 294 

444  Beginning  carcinoma  of  cervix 294 

445  Epithelioma,  cervix  destroyed 295 

446  Epithelioma,  cervix  destroyed  and  surface  infolded 296 

447  Epithelioma  of  cervix,  appearing  as  a  papillary  growth 297 

448  Showing  usual  origin  of  reflex  pains  in  the  various  regions 302 

Gynecologic  Treatment.  ^-jj^p      4     v 

449  Patient  arranged  for  long,  hot  vaginal  douche ' '"  .    "^    .     .     .  316 

450  Preparation  of  vaginal  tampons , 326 

451  Tampon-capsules 327 

452  Hodge  pessary  and  modifications 328 

453  Pessary  in  place     .      . 329 

454, 455     Introducing  pessary    334 

456,457     Introducing  pessary 335 

458  Introducing    pessary 336 

459  Introducing    pessary 337 

460  Flexible  ring  pessary,  inflated  ring  pessary  and  disk  pessary 340 

461  Menge  pessary 341 

462  Cup  and  belt  pessary 342 

463  Gehrung  pessary 342 

464  Introducing  Gehrung  pessary 342 

465  Skene  pessary 343 

466  Globe  pessary 343 

467  Applicators  for  intrauterine  treatment 350 

468  Knee-chest  posture 367 

469  Knee-chest  posture  with  pelvic  organs  outlined 368 

470  Knee-chest  posture  with  patient  draped  for  treatment 368 

471  Trendelenberg  posture 370 

Additional  Illustrations  for  Various  Diseases. 

472-475     Anatomy  of  Skene's  gland 378 

476  Veins  of  external  genitals 379 

477  Arteries  and  nerves  of  external  genitals 380 

478  Cross  section  of  vagina 381 

479  Gonococci  stained  in   pus 389 

480  Gonococci  much  enlarged  to  show  form 389 

481  Gonorrhoeal  pus  with  Gram's  stain 390 

.482     Pediculus  pubis 412 

483  Thrush  fungus 416 

484  Adhesive  vaginitis 417 

485  Excision  of  external  genitals 451 

486  Excision  of  varicose  veins  of  vulva 456 

487  Sectional  view  of  pelvic  floor,  diagrammatic 468 

488  Superficial  structures  of  pelvic  floor 469 

489  Levator  ani   muscles 470 


ILLUSTRATIONS  XXV 

FIC;.  PAGE 

490     Recto-vesical  fascia 470 

491-493     Pelvic  sling 471 

494  Pelvic  floor  from  above 472 

495  Deep  lateral  laceration  of  pelvic  sling  on  each  side 474 

496  Median  laceration  into  rectum,  but  not  into  sling 475 

497  Instruments  for  repair  of  pelvic  floor 481 

498  Recent  lacerations  from  labor 482 

499  Old  laceration  of  pelvic  floor 483 

500  Emmet's  operation  for  repair  of  pelvic  floor,  selecting  lateral  points     ....  484 

501  Emmet's  operation — Lines  of  tension 485 

502  Emmet's  operation — Denuding 485 

503  Emmet's  operation — Denuding 48G 

504  Emmet's  operation — Reason  for  excising  extra  tissue  from  sulcus 487 

505  Emmet's  operation — Excising  extra  tissue  from  left  sulcus 488 

506  Emmet's  operation — General  scheme  of  suturing 489 

507  Emmet's  operation — Area  of  denudation 490 

508  Emmet's  operation — Suturing  perineum 491 

509  Emmet's  operation — Periiieum  sutured 491 

510  Repairing  sphincter  ani,  ends  picked  up 493 

511  Sphincter  ani  sutured 493 

512  Hegar's  operation  for  repair  of  pelvic  floor 496 

513  Hegar's  operation — Buried  sutures 497 

514  Hegar's  operation — Superficial  sutures 498 

515  Tait's  operation  for  repair  of  pelvic  floor 499 

516  Tait's  operation — Incision  for   complete   tear 501 

517  Tait's  operation — Raising  flap 501 

518  Tait's  operation — Buried  sutures 502 

519  Tait's  operation — Trimming  off  excess  of  flap 502 

520  Tait's  operation — Suturing  vaginal  mucosa 503 

521  Tait's  operation — Suturing  perineal  surface 503 

522,  523     Hegar's  operation  for  cystocele 505 

524  Fistulae  of  genital  tract 506 

525  Course  of  needle  in  suturing  vesico-vaginal  flstula 514 

526  Regular  operation  for  vesico-vaginal  fistula 515 

527,  528     Flap  operation  for  vesico-vaginal  fistula 516 

529  Anterior  view  of  uterus 520 

530  Antero-posterior  section  of  uterus 520 

531  Uterus,  Fallopian  tube  and   ovary 521 

532  Reconstruction  of  uterus,  showing  shape  of  cavity 522 

533  Uterus  and  appendages  of  young  child 522 

534  Uterus,  tube  and  ovary  of  fourteen-year  old  girl 522 

535  Uterus,  tube  and  ovary  of  twenty-year  old  multipara 522 

536  Pelvic  contents  of  large  fetus 523 

537  Pelvic  contents  of  infant 523 

538  Comparisons  of  nulliparous  uterus  with  multiparous  uterus 524 

539  Relation  of  uterus  to  vagina  and  bladder 525 

540  Endometrium  of  infant 525 

541  Endometrium  of  child-bearing  period 526 

542  Endometrium  after  menopause 526 

543  Gland  and  stroma  of  endometrium 527 

544  Menstruating  endometrium 529 

545  Cervical   gland >  530 

546  Blood  supply  of  uterus 531 


XXVI  ILLUSTRATIONS 

FIG.  PAGE 

547  Blood  supply  of  uterus 532 

548  Lymphatics  of  uterus 533 

549  Distribution  of  uterine  lymphatics  to  various  groups  of  glands 534 

550  Ligaments  of  uterus 535 

551  Section  through  an  erosion  of  cervix 540 

552  Lacerated  cervix  with  erosion 551 

553  Instruments  for  repair  of  cervix 552 

554  Areas  for  denudation  for  repair  of  cervix 553 

555  Areas  for  denudation 554 

556  Incision  through  scar  tissue  at  the  angles 554 

557  Denudation  completed  and  sutures  passed  in  right  side 555 

558  Sutures  tied 555 

559  Section  through  cystic  cervix 558 

560  Area  for  amputation  in  cystic  cervix 558 

561  Line  of  excision  and  method  of  suturing  in  partial  amputation  of  cervix     .     .     .  558 

562  Partial  amputation  of  cervix 559 

563  Partial  amputation  completed 560 

564-567     Regular  amputation  of  cervix 561 

568     Normal  uterus  and  endometrium 568 

569, 570     Polypoid  endometritis 569 

571  Instruments  for  curettage 572 

572  Kitchen  table  arranged  for  curettage 573 

573  Patient  in  position  at  end  of  operating  table 574 

574,  575     Cleansing  vagina  after  patient  is  anesthetized 575 

576  Self-retaining  speculum  introduced 576 

577  Sterile  sheet  in  place 576 

578  Introducing  large  dilator 577 

579  Large  dilator  in  place 577 

580  Introducing  curet 578 

581  Method  of  holding  curet 578 

582  Returning  uterus  to  its  normal  position  after  curettage 579 

583  Putting  in  vaginal  packing 579 

584-587     Dressing  after   curettage 580 

588  T-bandage 581 

589  Section  of  endometrium  thirteen  days  after  curettage 581 

590  Section  of  endometrium  thirty-one  days  after  curettage 581 

591  Section  of  endometrium  three  months  after  curettage 582 

592  Section  of  endometrium  fifty-three  days  after  application  of  caustic     ....  582 

593  Section  of  pelvis  showing  normal  position  of  uterus 595 

594  View  from  above,  showing  position  of  uterus 596 

595-597     Bimanual  replacement  of  uterus 602 

598     Bimanual  replacement 603 

599,  600     Bimanual  replacement 604 

601  Puncturing  tenaculum-forceps 615 

602  Transplantation  of  round  ligaments 616 

603  Transplantation  of  round  ligaments 617 

604  Transplantation  of  round  ligaments 618 

605,  606     Multiple  fibromyomata  of  uterus 626 

607  Single  fibromyoma    • 627 

608  Diffuse  adeno-myoma  of  uterus 628 

609  Necrosis  of  part  of  intraligamentary  fibromyoma 628 

610  Necrosis  of  whole  fibromyoma 629 

611  Perforation  of  uterus  by  necrotic  fibromyoma 630 


ILLUSTRATIONS  XXVII 

PAGE 

Large  cystic  fibromyoma tj31 

Sarcoma  developed  in  cervical  stump  after  supravaginal  hysterectomy  for  fibro- 
myoma      032 

Section  of  original  fibromyoma.  showing  sarcomatous  areas 633 

Displacement  of  bladder  by  large  fibromyoma 034 

Epithelioma  of  cervix  associated  with  fibromyoma  of  corpus  uteri (j60 

Same  as  Fig.  616,  section  of  uterus  and  fibroid 662 

Epithelioma  of  cervix,  more  advanced 663 

Epithelioma  of  cervix,  in  late  stage 664 

Advanced  adeno-carcinoma  of  cervix 665 

Damage  to  ureters  and  kidneys  by  advanced  cancer  of  cervix 667 

Necessary  line  of  excision  in  radical  operation  for  cancer  of  cervix  uteri     .     .     .  677 

Beginning  carcinoma  of  corpus  uteri 687 

Carcinoma  of  corpus  uteri  in  advanced  stage 687 

Chorio-epithelioma  of  uterus 688 

Beginning  sarcoma  of  corpus  uteri 690 

Advanced  sarcoma  of  corpus  uteri 690 

Section  of  genital  tract,  showing  continuous  opening  into  peritoneal  cavity     .     .  692 

Section  of  Fallopian  tube  near  uterine    end 694 

Section  of  Fallopian  tube  near  fimbriated  extremity 694 

Connective  tissue  of  pelvis 697 

Thrombo-phlebitis 700 

Instruments  for  opening  pelvic  abscess 705 

Opening  pelvic  abscess — Incision  of  vaginal  wall 706 

Opening  pelvic  abscess — Blunt  dissection  through  connective  tissue     ....  707 

Opening  pelvic  abscess — Puncturing  abscess  wall 708 

Opening  pelvic  abscess — Drainage  tube  in  place 709 

Drainage  tube  with  cross-piece 710 

Drainage  tube  with  cross-piece,  another  method 711 

Same  as  Fig.  639 — Tube  in  place 711 

Opening  lateral  abscess 713 

Vaginal  section  for  acute  pelvic  inflammation — Sectional  view.     .          ....  715 

Vaginal  section  for  acute  pelvic  inflammation — View  from  above 716 

Proctoclysis  apparatus,  in  use  in  Murphy's  clinic 723 

Proctoclysis  apparatus,  one    easily    improvised 724 

Chronic  salpingitis,  mild 730 

Salpingitis,  with  exudate 731 

Pyosalpinx,  with  and  without  surrounding  exudate 732 

Diffuse  pelvic  suppuration 733 

Ovarian  abscess  and  tubo-ovarian  abscess 734 

Hydrosalpinx 735 

Nodular    salpingitis 736 

Pelvic  adhesions 736 

Pelvic  cellulitis  (parametritis) 737 

Various  situations  in  which  a  parametritic  mass  may  be  found 738 

Cystic   ovary 739 

Direction  of  extension  of  gonococcal  infection 749 

Direction  of  extension  of  streptococcal  infection 753 

Pelvic  tuberculosis,   peritoneal    form 761 

Pelvic  tuberculosis,  tubal  form 762 

Situation  of  ovum  in  various  forms  of  tubal  pregnancy 766 

Pelvic  hematocele 767 

Blood  mass  from  repeated  small  hemorrhages 768 


XXVIII  ILLUSTRATIONS 

MG,  PAGE 

664  Free  intraperitoneal  rupture  of  tube 769 

665  Free  intraperitoneal  hemorrhage 769 

666  Tubal  abortion — Tube  distended 770 

667  Tubal  abortion — Extruded  clots  and  embryo 77C 

668  Pelvic  hematoma 77C 

669  Mother  and  child  in  case  of  extrauterine  pregnancy  carried  to  near  term     .     .  771 

670  Treatment  for  varicose  veins  of  broad  ligament 797 

671  Showing  attachment  of  ovary  to  broad  ligament 799 

672  Section  of  ovary,  showing  hilum  and  medullary  portion  and  cortical  portion  .     .  799 

673  Graafian  follicle  and  ovarian  stroma 800 

674  Development  of  the  ovary 801 

675  Corpus  luteum 802 

676  Corpus  luteum,  very  large 802 

677  Corpus  luteum,  showing  interior  arrangement        . 802 

678  Lutein  cells 803 

679  Corpus  albicans 803 

680  Scars  in  ovary  .     .     .     .  " 804 

681  Parovarium  and  paroophoron,  embryonic 804 

682  Parovarium,  with  surrounding  structures 809 

683  Follicular  cysts  of  the  ovary 810 

684  Corpus   luteum   cysts 811 

685  Lutein  cells,  the  distinguishing  feature  in  the  wall  of  corpus  luteum  cysts     .     .  812 

686  Tubo-ovarian  cyst -  813 

687  Patient  with  large  ovarian  cyst 813 

688  Pseudo-mucinous  cyst,  with   jelly-like   contents 814 

689  Pseudo-mucinous  cyst,  showing  secondary  growths 815 

690  Lining  cells  of  pseudo-mucinous  cyst  and  of  serous  cyst  contrasted 816 

691  Small  serous  cyst,  showing  internal  papillary  projections 817 

692  Larger  serous  cyst 817 

693  Serous  cyst,  with  secondary  growths  projecting  through  wall 818 

694  Dermoid  cyst  of  ovary 821 

695  Dermoid  cyst  of  ovary 822 

696  Hair  switch  from  ovarian  dermoid 822 

697  Balls  of  sebaceous  material  from  dermoid  cyst 822 

698  Ovarian  cyst,  with  torsion  of  pedicle 829 

699  Small  parovarian  cyst 833 

700  Larger  parovarian  cyst 834 

701  Development  of  pelvic  organs,  indifferent  stage 837 

702  Development  of  pelvic  organs,  female 837 

703  Development  of  pelvic  organs,  male 837 

704  Development  and  malformations 838 

705  Development  of  external  genitals 839 

706  Pseudo-hermaphrodite,  external  view 846 

707  Pseudo-hermaphrodite,  explanatory  section 846 

708  Stem    pessaries 882 

709  Division  of  cervix  uteri  for  dysmenorrhoea 885 

710  Dividing  cervix 880 

711  Suturing  divided  cervix     . 886 

712  Suturing  in  front  of  cervix 887 

713  Safe  position  of  arms  during  anesthesia 917 

714  Dangerous  position   of  arms  during  anesthesia 918 

715  Dissection  showing  compression  of  brachial  plexus 919 

716  Diagram  of  brachial  plexus,  showing  location  of  involved  area 920 


ILLUSTRATIONS?  XXIX 

FIG.  PA(;l.; 

717  Arm  hanging  over  table,  a  position  of  danger  during  anesthesia 921 

718  Dressing  abdominal  incision 922 

719  Dressing  abdominal  incision 922 

720  Dressing  abdominal  incision 923 

721  Dressing  abdominal  incision 924 

722  Gauze-strip  sponges  for  abdominal  surgery 929 

723  Gauze-strip  sponges  for  abdominal  surgery 930 

724  Gauze-strip  sponges  for  abdominal  surgery 930 

725  Gauze-strip  sponges  for  abdominal  surgery 930 

726  Gauze-strip  sponges  for  abdominal  surgery 931 

727  Gauze-strip  sponges  for  abdominal  surgery 931 

728  Conservative  surgery  of  ovary  and  tube 946 

729  Strapping  abdomen  after  removal  of  sutures 951 

730  Cutting  adhesive  straps  for  inspection  of  healed  incision 952 

731  Scar  exposed     .    , 953 

732  Drainage  tube,  with  sheet-rubber  in  place  to  protect  general  dressing     ....  954 

733  Gauze  wick  and  applicator  for  emptying  drainage  tube 954 

734  Gauze  pieces  about  end  of  tube 954 

735  Sheet-rubber  folded  over  gauze 954 

736  Tray  of  articles  for  care  of  drainage  tube 955 

737  Syringe  and  catheter  for  rapid  removal  of  large  quantity  of  fluid  from  tube  .     .  956 

738  Elevation  of  head  of  bed  for  drainage  immediately  after  operation 957 

739  Regular  Fowler  posture 958 

740  Elevation  of  foot  of  bed  for  treatment  of  shock 959 

741  After-treatment  in  vaginal  operations — Pitcher  douche 965 

742  After-treatment  in  vaginal  operations — "Vulvar  dressing 966 

743  Catheterization — Keeping  the  labia  apart 967 

744  Catheterization — Grasping  the  catheter  some  distance  from  the  point     .....  967 


Fig.  1.     Antero-posterior  Section  of  Pelvis  (semi-diagrammatic).     (R.  Walter  Mills.) 

In  order  to  .show  the  structures  and  relations  exactly  as  they  are  in  what  may  be  considered  a  typical 
woman  in  the  erect  posture,  the  artist,  Dr.  Mills,  made  a  detailed  study  of  many  drawings  from  frozen  sec- 
tions for  the  internal  relations,  and  of  several  well-formed  women  in  the  normal  standing  posture  for  the 
contour  anrl  external  relations.  This  gave  a  result  differing  considerably  from  the  usual  representation  of 
a  patient  standing,  made  by  taking  a  drawing  of  a  section  of  a  flattened  cadaver  and  turning  it  upright. 
The  lumbar  curve  is  more  marked,  the  lower  abdominal  wall  and  the  buttocks  are  more  prominent  and 
there  is  a  change  of  the  relations  of  the  internal  organs  to  the  external  landmarks. 

For  the  internal  relations  the  admirable  frozen  sections  of  Sellheim  were  principally  followed,  and  the 
exactness  with  which  the  pelvis  and  contents  of  the  actual  sections  fitted  into  the  contours  of  the  living 
models  was  most  pleasing  and  instructive. 


DISEASES  OF  WOMEX 


CHAPTER  I. 

GYNECOLOGICAL  EXAMINATION  METHODS. 

The  physician  who  wishes  to  do  accurate  work  in  diagnosis  nmsl  he  in  pos- 
session of  certain  facts,  as  follows : 

Knowledge  of  the  anatomy  and  physiology  of  the  organs  involved. 
Reliable  history  and  examination  of  the  patient. 
Knowledge  of  the  diseases  to  which  the  parts  are  liable. 

The  essential  organs  in  the  group  of  structures  involved  in  gynecological* 
diseases  are  shown  in  Figs.  1,  3,  4,  5  and  6.     They  are  as  follows : 

1.  The  ovaries,  in  which  the  ova  are  formed. 

2.  The  Fallopian  tubes,  which  conduct  the  ova  from  the  ovaries  to  the 

uterus. 

3.  The  uterus,  which  receives  and  nourishes  the  fertilized  ovum  and 

expels  the  fetus  at  term. 

4.  The  vagina,  which  is  the  connecting  link  between  the  uterus  and 

the  outside  world. 

There  are  also  several  accessory  structures — namely,  the  external  genitals, 
the  perineum,  the  pelvic  floor,  the  pelvic  peritoneum  and  the  pelvic  connective 
tissue. 

The  gross  anatomy  of  these  organs  and  the  prominent  facts  in  their  physi- 
ology are  sufficiently  known  to  you,  from  general  anatomical  and  physiological 
study,  to  permit  immediate  consideration  of  the  methods  of  obtaining  the  facts 
on  which  a  diagnosis  may  be  based. 

HISTORY. 

When  called  to  see  a  patient  with  pelvic  disease,  the  first  thing  to  do  is  to 
obtain  what  information  the  patient  can  give  concerning  her  trouble.  This 
information,  obtained  from  the  patient  or  her  friends,  is  called  the  history, 
and  should  include  facts  covering  the  points  mentioned  below. 


*  As  to  the  pronunciation  of  "gynecology,"  the  weight  of  authority  is  decidedly  in  favor  of  soft  g,  short  y 
and  the  accent  on  the  third  syllable-jin  e  kol'  o  je  (Webster's  Unabridged  Dictionary.  Century  Dictionary, 
Standard  Dictionary,  Gould's  Medical  Dictionary.  Keating's  Medical  Dictionary).  A  few  authorities  differ, 
some  favoring  soft  g  and  long  y,  and  others  favoring  hard  g  and  long  y. 


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Fig.  2.  A.  Exact  Contour  and  Measurements  of  the  woman  selected  for  Fig.  1.  B.  E.xact  Contour  and 
Measurements  of  another  model,  presenting  a  more  pronounced  lumbar  and  abdominal  curve.  The  small 
squares  represent  one-inch  squares  at  life  size.     (R.  Walter  Mills.) 

(A)  Artist's  model,  aged  28,  mother  of  two  children  (6  and  8  years  old  respectively),  has  worn  corset  prac- 
tically none,  is  in  good  health  and  fairly  muscular.  Height  5  ft.  7  in.,  weight  140  lbs.,  bust  measure  36  in., 
waist  27  in.  (2  in.  above  umbilicus),  circumference  at  umbilicus  30  in.,  hips  30  in.,  thigh  22  ,'<>  in.  (2  in.  below 
gluteal  crea.se),  antero-posterior  diameter  of  body  at  waist  6  ji  in.,  antero-posterior  diameter  of  thigh  (2  in.  below 
gluteal  crease)  6  j^^in.  The  other  data  are  given  on  the  outline.  To  conform  to  the  so-called  "perfect  form"  the 
hips  should  be  a  trifle  larger  and  the  weight  somewhat  more. 

(B)  Young  woman,  aged  27,  never  pregnant,  has  worn  corset  very  little,  is  in  good  health  and  muscular. 
Height  5  ft.  4  in.;  weight  114  lbs.,  bust  measure  32  in.,  waist  24  in.  (2  in.  above  umbilicus),  hips  38  in.,  thigh 
22  in.  (2  inches  below  gluteal  crease),  antero-posterior  diameter  of  body  at  waist  6  V2  in-,  antero-posterior  diam- 
eter of  thigh  (2  inches  below  gluteal  crease)  6  -^g  in.  The  other  data  are  given  on  the  outline.  The  lumbar  and 
abdominal  curves  are  more  pronounced  than  in  (A). 

The  numerous  exact  measurements  given  in  Fig  2  constitute  valuable  data  to  guide  in  medical  drawings  ol 
this  character. 


TAKINC  THK  HISTORY  3 

Present  Symptoms. 

Of  what  symptoms  does  tlio  patient  complain?  A  question  directed  to  bring 
out  this  information  Mill  at  once  enlist  the  patient's  interest  and  relieve  any 
temporary  embarrassment  she  may  feel.  The  ])roininent  symptoms  are  soon 
given  and  serve  to  indicate  lines  of  special  iiKpiiiy  when  taking  the  systematic 
history  of  the  case. 


Fig.  3.  Antero-posterior  Section  of  Pelvis.  Showing  left  half  of  body,  with  intestines  removed.   (Kelly — 
Operative  Gynecology.) 


The  systematic  inquiry  is  begun  at  some  convenient  point  in  the  patient's 
narrative. 

Beginning  of  Present  Trouble. 

How  long  has  the  patient  been  sick?  Ascertain  accurately  when  the  present 
trouble  began.  If  it  is  of  long  duration,  pass  back  of  the  several  exacerbations 
and  get  the  approximate  date  of  the  first  acute  attack  or  first  appearance  of 
decided  symptoms. 


4 


TAKING  THE  HISTORY 


What  were  tliese  first  symptoms"?  How  severe  were  they?  "What  was  done 
for  them  ? 

What  caused  the  trouble  at  that  time  ?  Had  there  been  a  severe  sick  spell  or 
an  injury  of  any  kind?    Had  there  been  a  labor  or  miscarriage,  or  menstrual 


Fig.  4.     View  of  Pelvic  Organs  from  Behind.     (Dickinson — American  Text-Book  of  Ohstetrics.) 


Fig.  5.     Pelvic  Organs  from  in  Front.     (Dickinson— ^m.  Text-Book  of  Obstetrics.) 

disturbance  or  recent  marriage,  or  extra  work  or  anything  that  might  have 
acted  as  a  cause? 

Character  and  Duration  of  Principal  Symptoms. 

Get  an  account  of  the  present  trouble  from  tlie  day  it  began,  down  througli 
all  the  important  changes,  to  the  date  of  consultation.    This  does  not  mean  to 


THE  PRINCIPAL  SYMPTOMS 


"waste  time  with  a  mass  of  iinuecessary  detail,  but  to  ascertain,  by  well-directed 
inquiries,  the  order  of  developmeut  and  the  duration  of  the  i)rincipal  symp- 
toms, such  as  pain,  fever,  swelling,  discharge,  etc. 

Locate  definitely  the  site  of  the  pain  or  tenderness  or  other  distress  com- 
plained of.  Is  it  in  the  tubal  region  or  appendix  region,  or  over  the  uterus  or 
about  the  ureter  or  kidney?  Have  the  patient  point  out  the  exact  location  of 
the  pain.  Figs.  7  to  15  indicate  the  location  of  the  pain  in  various  afifections. 
This  definite  localization  helps  to  clarify  the  situation  and  makes  the  patient 
more  careful  and  reliable  in  her  statements. 

Of  course  no  diagnosis  shoidd  be  attempted  from  such  necessarily  uncer- 


Fig.  6.     Relation  of  the  Pehic  Organs  to  the  External  Surface  of  thelbody. 
of  Obstetrics.) 


(Dickinson — Am.     Text-Book 


tain  localization  by  the  patient.  This  simply  indicates  what  group  of  organs 
are  probably  aflfected  and  thus  enables  the  physician  to  question  the  patient 
more  definitely  and  accurately  before  beginning  the  physical  examination. 

Ascertain  also  the  effect  of  the  disease  on  the  general  health.  As  to  this 
effect,  we  have  two  guides— the  weight  and  the  activity  of  the  patient.  How 
much  has  she  lost  in  weight,  or  has  she  gained?  How  much  of  the  time  has 
she  been  confined  to  bed?  If  able  to  be  up  and  about  part  of  the  time,  or  all 
of  the  time,  how  much  work  or  walking  or  shopping  has  she  been  able  to  do  ? 


b  TAKING  THE  HISTORY 

Ascertain  also  the  frequency  and  duration  of  the  exacerbations  of  the  dis- 
ease. Has  the  trouble  been  getting  worse  gradually  and  continuously,  or 
have  there  been  exacerbations,  followed  by  remissions,  with  partial  or  com- 
plete disappearance  of  the  symptoms  ? 

Inquire  also  concerning  complications.  Frequently  there  are  complicating 
bladder  or  rectal  disturbances  or  other  associated  local  diseases,  and  the  extent 
of  these  should  be  determined. 

Previous  Health. 

Has  the  patient  previously  been  well  and  strong?  Any  serious  sickness, 
whether  connected  with  the  pelvic  organs  or  not,  should  be  inquired  into.   It 


Fig.  7.  Indicating  General  Pel%ic  Distress.  This 
distress  may  be  due  to  bladder  or  uterine  or  tubal  or 
ovarian  disease  on  one  or  both  sides. 

may  be  an  important  factor  in  the  origin  of  the  present  disturbance  or  it  may 
point  to  some  complication  that  must  be  taken  into  consideration  in  the  treat- 
ment. 

Age,  Married,  Address,  Occupation. 

This  stage  of  the  conversation  is  a  convenient  time  to  note  the  necessary 
facts  not  strictly  medical.  You  may  now  ask  the  patient  her  age,  occupation, 
etc.,  without  the  questions  appearing  irrelevant. 

If  married,  how  long?  If  she  has  been  married  more  than  once  or  if  she  is 
a  Avidow,  she  will  probably  mention  the  fact  and  also  any  correlated  facts 
bearing  on  the  present  disturbance. 

The  securing  of  the  patient's  address  comes  in  very  well  here.  Also  other 
similar  items  of  information  that  it  may,  for  business  reasons,  be  advisable 


CONFINEMENTS  7 

to  note  in  some  eases — for  example,  the  husband's  occupation  and  business 
address. 

Is  the  patient  engaged  in  any  work  aside  from  her  liouschobl  duties?  If  so, 
what  is  it  and  has  it  any  bearing  on  the  origin  or  continuation  of  the  present 
trouble?  Does  she  do  any  of  her  housework?  If  so,  how  much?  Is  it  executed 
with  facility,  as  when  she  was  well,  or  is  there  pain  and  disability?  Ascertain 
accurately  the  character  of  the  distress  associated  with  the  work.  What  time 
of  day  does  it  come  on,  where  is  it  located,  is  it  a  sharp  pain  or  a  dull  aching, 
or  a  dragging  weight  and  pressure?  What  posture  aggravates  or  relieves  it, 
does  it  necessitate  lying  down,  does  it  recur  soon  after  rising,  is  it  present 
every  day,  does  it  vary  from  week  to  week  or  from  month  to  month? 

Confinements. 

Has  the  patient  had  children?  If  so,  how  many  and  when?  Was  there 
serious  trouble  during  any  labor  or  during  any  pregnancy  or  afterward?  Make 
particular  inquiry  as  to  whether  the  labor  was  so  severe  that  instruments  had 


Fig.  8.    Backache  from  pehic  disease.    Indicating 
pain  in  the  central  lumbar  region. 


Fig.  9.      Backache  from  pelvic  disease, 
ing  pain  extending  down  over  the  sacrum. 


Indicat- 


to  be  used,  or  whether  the  labor  was  followed  by  indications  of  sepsis  or  of 
laceration  of  the  pelvic  floor  or  cervix  uteri. 

If  after  any  labor  the  patient  was  sick  in  bed  for  two  or  three  weeks,  with  pain  in 
the  lower  abdomen  and  fever,  she  probably  had  sepsis  in  some  form,  the  usual  form 
being  septic  endometritis.  Another  very  common  history  of  mild  sepsis  is  that  the 
patient  gets  up  as  usual,  but  does  not  feel  strong,  and  after  a  few  days  takes  a  "backset," 
and  returns  to  bed  or  drags  about  the  house  with  soreness  in  the  lower  abdomen,  some 
fever  and  marked  weakness.  Of  course,  delays  in  convalescence  after  labor  may  be 
caused  by  complications  outside  the  genital  tract,  but  generally  they  are  due  to  some 
trouble  in  the  genital  tract,  such  as  infection  of  the  uterus  or  subinvolution  of  the  uterus 
or  laceration  of  the  pelvic  floor. 


8 


TAKING  THE   HISTORY 


Miscarriages. 

Have  there  been  any  miscarriages  ?  If  so,  how  many  and  when,  and  at  what 
stage  of  pregnancy  did  each  occur  ? 

A\"hat  was  the  cause  of  each  miscarriage?  Did  it  follow  some  accident  or  was 
it  due  to  some  acute  disease,  such  as  typhoid  fever  or  pneumonia?  If  there 
have  been  repeated  miscarriages,  inquire  carefully  and  circumspectly  as  to 
evidences  of  syphilis.  Have  the  miscarriages  been  brought  about  intentionally 
(criminal  abortion) — if  so,  in  what  way? 

Was  each  miscarriage  complete  and  no  trouble  following?  When  incomplete, 
part  of  the  fetal  membranes  are  retained  in  the  uterus  and  cause  a  persistent 
bloody  discharge.   Sepsis  also  may  occur. 


Fig.  10. 
region. 


Indicating  pain  in  right  tubo-ovarian  Fig.  11.     Indicating  pain  in  tlie  appendiceal  region. 


Sterility. 

When  the  patient  has  been  married  a  long  time  and  there  has  been  no  preg- 
nancy, it  is  well  in  some  cases  to  inquire  as  to  why  there  has  been  no  preg- 
nancy. 

Menstrual  History. 

How  old  was  the  patient  when  she  began  to  menstruate?  Has  the  men- 
struation been  regular  and  of  proper  duration  and  amount,  and  free  from 
severe  pain?  If  there  have  been  menstrual  disturbances — for  example,  ab- 
sence of  the  menses  or  excessive  menstruation,  or  irregular  menstruation  or 
inter-menstrual  bleeding — ascertain  the  duration  and  severity  of  each. 

Last  Menstruation. 

Invariably  ascertain  the  date  and  duration  of  the  last  menstruation,  that 
pregnancy  may  be  excluded. 


ASSOCIATED  DISEASES 


Disturbances  of  Other  Organs. 
Inquiry  should  be  made   as  to  indications  of  diseases  in  remote   organs, 
either  complications  of  the  pelvic  trou])le  or  iutercurrent  diseases. 


Fig.  12.    Indicating  pain  in  the  region  of  the  stomach. 


Fig.  13.     Indicating  pain  in  the  liver. 


Fig.  14.     Indicating  pain  in  the  region  of   the  right 
kidney. 


Fig.  15.  Another  common  way  of  indicating  the 
dragging  pain  that  accompanies  di.sease  and  dis- 
placement of  the  kidney. 


If  the  patient  gives  any  symptoms  pointing  to  disease  of  remote  organs — 
for  example,  of  the  heart  or  lungs  or  gastro-intestinal  tract — those  organs 
should  be  examined.  In  case  of  serious  disease,  and  in  all  cases  where  an 
anesthetic  is  to  be  given,  an  examination  of  the  heart  and  lungs  and  abdomi- 
nal viscera  is  imperative. 


10  TAKING  THE  HISTORY 

The  condition  of  the  patient's  blood,  as  indicated  by  her  color,  and  the 
condition  of  the  nervous  system,  as  indicated  by  her  appearance  and  actions, 
should  be  considered,  and,  if  there  is  evidence  of  disease  in  either  direction, 
further  investigation  should  be  carried  out. 

The  urine  should  be  examined  if  the  patient  is  seriously  sick  or  if  there 
are  symptoms  pointing  to  bladder  or  kidney  disease,  or  if  an  anesthetic  is  to 
be  given. 

Previous  Treatment. 

Question  the  patient  as  to  the  character  and  duration  of  the  previous  treat- 
ment and  its  apparent  effect.  AVas  it  internal  treatment  only  or  local  treat- 
ment at  home  (douches,  vaginal  suppositories  or  tablets  or  tampon-capsules), 
or  local  treatment  at  office  (vaginal  applications,  tampons,  intra-uterine 
treatment),  or  operation  (curetment,  repair  of  pelvic  floor  or  cervix,  vaginal 
section  or  abdominal  section)  ? 

Special  Points. 

Each  of  the  above  mentioned  points  should  be  inquired  into  in  practically 
every  case  of  pelvic  disease.  In  exceptional  cases  it  is  necessary  to  make 
inquiry  along  special  lines — for  example,  in  regard  to  the  patient's  family 
history  (nervous  diseases,  tuberculosis,  cancer),  or,  as  in  sterility,  in  regard  to 
the  husband's  health. 

Summary  of  Chief  Symptoms  Demanding  Relief. 

After  completing  the  history  and  before  beginning  the  examination,  fix 
in  mind  the  chief  symptoms  for  which  the  patient  seeks  relief.  Keep  these 
in  mind  while  making  the  examination  and  endeavor  to  find  the  lesion  or  con- 
dition that  causes  each  of  them.  These  symptoms  serve  to  indicate  the  direc- 
tions for  special  investigation.  The  diagnosis  should  be  made,  to  a  consider- 
able extent,  as  the  examination  progresses.  Before  finishing  the  examination 
you  should  know  whether  or  not  you  have  found  the  cause  or  causes  of  the 
symptoms  that  brought  the  patient  to  you. 

Keep  a  Record. 

As  to  whether  or  not  a  record  is  kept,  and,  if  so,  in  what  way,  depends  of 
course  on  the  inclination  of  the  physician.  However,  if  he  does  not  keep  a' 
record  of  cases,  he  deprives  himself  of  something  valuable.  A  short  record, 
giving  in  a  systematic  way  the  principal  facts  of  a  case,  may  be  made  quickly 
and  more  than  repays  for  the  time  consumed.  And  the  principal  advantage 
is  not  the  permanent,  record  it  gives  for  reference  after  some  years  (though 
this  is  important,  especially  to  the  teaclier),  but  the  fact  that  it  systematizes 
and  steadies  and  improves  the  physician's  work  day  by  day.  Such  an  ac- 
count of  the  case  in  black  and  white,  referred  to  frequently,  as  the  patient 
returns  for  treatment,  is  a  constant  stimulus  to   accurate  diagnosis  and  a 


THE  WRITTEN   RECORD 


11 


constant  help  in  the  treatment,  particularly  if  the  case  is  a  long  continued 
one.  Again,  in  court  tlie  physician  is  supposed  to  have  some  record  of  his 
work.  You  nmy  at  any  time  be  called  upon  to  testify  as  to  the  exact  findings 
in  the  case  of  some  patient  whom  you  saw  one  or  two  or  three  years  before. 


DATE 

NAME 

ADDRESS 

oc 

met.  BY 

PREVIOUS   M. 

CONFIX. 

MISC. 

«EG. 

0      A                                                                                     PAIN 

WITH  ILL.  RCa. 

KAIN 

L«»T  MENSTR 

PRESENT    ILLNESS 

EXAM.  >ND  DIAG 

Fig.    16. 

Gynecological  History  Card. 

The  original  card  is  6  in.  wide  and  4  in.  liigh. 

OUTLINE   OF   TR. 

CH. 

PD. 

□  ATE     . 

NOTES 

Fig.  17.     Rever.s'i  side  of  History  Card. 


12  '  TAKING  THE  HISTORY 

The  record  should  embody  the  important  facts  in  the  history,  in  the  exami- 
nation findings,  in  the  treatment  given,  and  in  the  subsequent  progress  of 
the  ease.  The  great  drawback  to  records  is  the  time  required  to  make  them. 
In  order  to  make  them  at  all,  the  physician  must  have  some  arrangement  by 
which  the  record  may  be  made  in  a  very  few  minutes.  Here  comes  in  the 
utility  of  printed  forms.  On  a  printed  form  the  physician  may,  in  a  few 
minutes,  put  down  the  notes  necessary  to  make  an  accurate  account  of  the 
case. 

Record  cards,  printed  as  desired,  and  arranged  as  a  card-index,  constitute 
the  most  convenient  record  system  for  the  busy  practitioner,  and  at  a  moder- 
ate cost. 

I  use  4x6  cards,  printed  on  one  side  for  the  principal  record  (Fig.  16),  the  back  of 
the  card  being  used  for  extra  notes  (Fig.  17).  When  more  space  is  required,  blank  cards 
are  attached  as  needed. 

When  it  is  desired  to  have  a  sketch  of  the  condition,  a  small  outline  of  the  pelvis  or 
abdomen  is  stamped  at  some  clear  space  on  the  card  with  the  required  rubber  stamp  (of 
which  any  desired  kinds  may  be  obtained  at  small  expense),  and  the  tumor  or  inflam- 
matory mass,  or  displaced  organ  is  then  drawn  in. 

I  use  three  kinds  of  form-cards,  all  the  same  size,  but  differing  in  color.  For  the  gyneco- 
logical cases  I  use  a  white  card  and  for  the  obstetrical  cases  a  salmon  card.  For  the 
obstetrical  drawer  there  are  two  sets  of  monthly  index  cards,  one  blue  and  the  other 
manila.  When  the  obstetrical  patient  first  comes,  the  clinical  notes  are  made  as  to  last 
menstruation,  any  disturbances,  time  for  regular  examination,  etc.,  and  the  card  is  placed 
under  the  blue  index  card  for  the  month  of  examination.  So  by  a  glance  I  can  tell  just 
what  patients  are  awaiting  examination  each  month.  When  the  examination  is  made, 
the  findings  are  noted  and  the  card  is  then  placed  under  the  manila  index  for  the  month 
of  delivery.  After  labor  the  card  is  finally  noted  up  and  placed  in  the  general  card-index 
of  patients,  that  it  may  be  readily  referred  to  at  any  time.  My  operation  cards  are  of 
the  same  size,  but  a  different  color,  so  that  they  also  may  be  easily  distinguished  from 
the  other  cards  of  the  general  index. 

Jf  one  does  not  wish  to  invest  in  specially  prepared  cards  and  holders,  a 
start  may  be  made  with  some  blank  cards  of  the  desired  size,  arranged 
upright  in  the  ordinary  desk  drawer. 

Is  a  Pelvic  Examination  Required? 

After  obtaining  all  the  information  the  patient  can  give  concerning  her 
illness,  the  next  step  is  to  make  the  physical  examination,  provided  there  are 
symptoms  making  such  an  examination  necessary. 

In  the  case  of  a  virgin,  pelvic  examination  is  rarely  indicated  until  after 
general  therapeutic  measures  have  been  tried  and  have  failed  to  give  relief. 
Occasionally  a  young  woman  or  a  girl  will  present  sucli  serious  syinptoins  tliat 
an  examination  is  indicated  at  the  first  visit,  but  such  cases  are  extrenu'ly 
rare. 

On  the  other  hand,  in  the  case  of  a  married  woman,  if  decided  pelvic 
symptoms  are  present,  an  examination  should  as  a  rule  be  made  at  once, 
particularly  if  there  has  been  previous  treatment  without  satisfactory,  result, 


WIIKN    TO   MAKE  AN    KXAMIN ATlON 


13 


In  such  a  case,  wlien  the  patient's  account  of  the  trouble  is  finished,  say 
to  lier  that  an  examination  is  necessary  in  order  to  determine  the  exact  con- 
dition present. 

Usually  the  patient  was  aware  that  an  examination  would  be  necessary  and 
came  for  that  purpose.  If  not,  she  may  make  some  slight  protest,  which  may 
he  waived  aside.  If  she  expresses  a  decided  preference  for  another  time,  an 
appointment  may  be  made  for  some  other  day.  If  the  patient  is  menstruat- 
ing, the  examination  is  of  course  postponed,  unless  the  symptoms  are  very 
serious  and  urgent.  A  non-menstrual  bloody  discharge  is  not  a  contra- 
indication to  examination,  but  rather  an  additional  indication  for  it. 

If  tlie  patient  is  extremely  anxious  to  avoid  the  examination,  treatment 
without  it  may  be  tried  for  a  while  in  a  suitable  case,  even  though  immediate; 
examination  seems  decidedly  preferable. 

When  a  girl  is  examined,  her  mother  or  some  other  relative  should  be 
present. 

PHYSICAL  EXAMINATION. 

The  order  of  examination  which  I  find  most  convenient,  when  the  patient 
can  be  placed  on  the  table,  is  as  follows : 
Abdominal   examination. 

Inspection  of  external  genitals,  meatus,  perineum,  etc. 
Vaginal  examination    (digital). 
Vagino-abdominal  examination   (bimanual). 
Instrumental  examination. 


Fig.  18.    Patient  on  table  and  arranged  for  abdominal  examination. 


14 


THE   PHYSICAL  EXAMINATION 


Exceptionally. 

Examination  of  rectum. 

Pelvic  examination  under  anesthesia. 

Examination  of  bladder. 

When  the  patient  is  seen  at  home,  the  order  of  examination  is  more  fre 
quently  abdominal,  vaginal,  vagino-abdominal  and,  when  indicated,  a  digital 
examination  per  rectum.    Inspection  of  the  external  genitals  and  the  specu- 
lum examination  are  usually  not  required  in  such  a  case  (page  108). 

However,  if  there  are  symptoms  pointing  to  disease  of  the  external  genitals, 
the  parts  should  of  course  be  inspected.  Also,  in  any  case,  if  it  is  thought 
that  information  of  value  may  be  obtained  by  the  speculum  examination,  that 
procedure  should  be  carried  out. 


Fig,  19,     Profile  of  Normal  Abdomen,     Patient  arranged  for  abdominal  examination. 


.^^ 


ABDOMINAL  EXAMINATION. 

Have  the  patient  lie  near  tiie  edge  of  the  bed  or  table,  in  a  comfortable 
position,  with  the  head  slightly  raised  on  a  pillow  and  the  knees  drawn  up 
sufficiently  to  relax  the  abdominal  muscles  (Figs.  18,  112). 

The  abdomen  is  subject  to : 

Inspection — Contour,  Color,  Eruption,  Striae,  Scars. 
Palpation — Tension,   Tenderness,   Mass,    Fluctuation,    Fluid    Wave, 
Fat  Wave;  Fetal  MoTement,  Uterine  Contraction,  Friction  Rub. 
Percussion — Area  of  Dullness. 

Auscultation — Fetal  Heart  Sounds,  Vascular  Murmur. 
^—"Menstruation — For  accurate  comparison. 


THE   ABDOMINAL   EXAMINATION 


15 


iii 


Fig.  20.     Normal  Abdomen.    The  patient  is  tall  ami  rather  slender.     Notice  how  the  anterior  superior  iliac 
spines  stand  out  as  landmarks. 


16 


THE  PHYSICAL  EXAMINATION 


INSPECTION  OF  ABDOMEN. 

Contour,  Movement,  Color,  Eruption,  Striae,  Scars. 

The  principal  thing  to  determine  by  inspection  is  contour.  Determine  also 
the  other  items  mentioned — movement  of  wall,  color,  eruption,  striae,  scars — 
but  usually  they  are  of  secondary  importance.  As  to  contour,  there  may  exist 
one  of  several  conditions,  as  follows : 


FiK.  21 .     The  abdominal  surface  with  the  rib  margins  and  the  iliac  crests  outhned. 


The  smootli,  moderately  full  contour  of  tlie  normal  abdomen  (Figs. 

19,  20,  21,  22). 
The  flat,  sunken  alxlomen  of  wasting  disease,  with  empty  intestines. 
A  swollen,  prominent  abdomen. 


PALPATION  OF  THK   ABDOMEN 


17 


The  significance  of  prominence  of  the  ahdoincn   is  taken  up   in   detail    in 
the  chapter  on  Diagnosis  (page  120). 

PALPATION  OF  ABDO:\IEX. 

Tension,  Tenderness,  Mass,  Fluctuation,  Fluid  Wave,  Fat  Wave,  Fetal  Move- 
ment, Uterine  Contraction,  Friction  Rub. 


vi 


/        \ 


Fig.  22.     Another  abdominal  surface,  with  the  ribs  and  crests  outlined.     This  patient  is  rather  stout.     Notice 
how  much  the  landmarks  ditler  from  those  in  Fig.  21. 


Texsiox   and   Tenderness. 

As  to  tension,  we  determine  whether  the  wall  is  soft  and  easily  depressed, 
or  is  firm  and  resisting  from  muscular  tension.    The  latter  condition  may  be 


18 


THE  PHYSICAL  EXAMINATION 


due  to  nervousness  or  fright,  the  patient  fearing  that  the  examination  will 
cause  pain,  or  it  may  be  due  to  genuine  tenderness  from  inflammation  or  irri- 
tation beneath  the  wall,  as  in  peritonitis  or  intraperitoneal  hemorrhage. 
The  best  way  to  begin  palpation  is  to  place  the  palmar  surface  of  the 


Fig.  23.     Palpation  of  the  abdomen.     First  step. 
Hand  flat  on  abdominal  surface 


Fig.  24.     Palpation.     Depressing  the  wall  with 
the  fingers  of  one  hand,  in  various  situations. 


FIk.  2.'),     Palpation  witli  both  hands. 


Fig.  26.     Dfej)  Palpation  witii  i)otli  lui'ndtj. 


METHOD  OF  PALPATION 


19 


whole  hand  flat  on  the  abdominal  wall  (Fig.  23).  Hold  it  there  perfectly 
quiet  for  a  moment,  that  the  patient  may  see  that  you  are  not  going  to  cause 
pain.  Then,  as  the  muscular  tension  relaxes,  depress  the  wall  carefully  with 
the  fingers  (Fig.  24)  in  various  directions  and  situations  as  the  hand  is  moved 
about  over  the  surface.  Begin  the  movement  of  the  hand  gradiudly,  almost 
impereeptil)ly  at  first,  perhaps  at  the  same  time  directing  the  patient 's  atten- 
tion away  by  a  question  or  two.  When  the  patient's  attention  is  fixed  on  llie 
palpating  liands,  th(n-e  is  likely  to  be  troublesome  tension  of  the  wall.     As  the 


Fig,  27,     The  abdominal  surface  divided  into  Quadrants 


examination  proceeds,  deep  palpation  is  made  in  various  parts  of  the  abdo- 
men in  order  to  exclude  disease  in  the  various  regions.  Palpation  with  both 
hands  (Fig.  25)  assists  much  in  determining  the  character  and  consistency 
of  the  tissues  between  them  and  under  them,  particularly  when  the  abdomen 
is  rather  full.  If  a  resisting  area  is  found,  work  the  fingers  around  it,  de- 
pressing the  wall  and  examining  all  portions  of  it  (Fig.  26).  The  palpation 
should  always  be  made  gently,  for,  if  the  manipulations  cause  pain  or  frighten 
the  patient,  the.  wall  is  immediately  made  tense  and  then  no  satisfactory  ex- 
amination is  possible. 


20 


THE  PHYSICAL  EXAMINATION 


Having  determined  the  general  tension  and  tenderness,  search  is  made  for 
local  tenderness.  The  exact  location  of  the  tenderness  should  be  carefully 
determined,  and  also  whether  it  is  circumscribed  to  that  area  or  extends  to 
other  areas.  When  the  area  of  tenderness  has  been  accurately  located,  we 
know  what  organs  are  likely  to  be  affected,  and  the  further  differentiation 
between  affections  of  those  organs  may  be  proceeded  with. 

Regions  of  the  Abdomen.    For  convenience  in  designating  the  location  of 


Fig.  28.  The  usual  anatomical  division  of  the  abdomen  into  nine  regions  by  two  transverse  lines  and  two 
vertical  lines.  The  upper  transverse  line  is  at  the  level  of  the  cartilages  of  the  ninth  ribs,  and  the  lower  with 
the  highest  points  of  the  iliac  crests.  The  two  parallel  vertical  lines  pass  through  the  cartilages  of  the  eighth 
ribs  and  the  middle  of  Poupart's  ligaments. 


tenderness  or  of  a  mass,  the  abdomen  is  divided  into  regions.  There  are  many 
methods  of  division.  A  simple  and  useful  one  is  the  division  of  the  surface 
into  quadrants  by  an  imaginary  liorizontal  line  passing  through  the  umbili- 
cus and  a  vertical  line- through  the  same  point  (Fig.  27). 

This  is  very  convenient  for  designating  in  a  general  way  the  location  of 
large  masses,  but  it  is  not  sufficiently  definite  for  the  accurate  localization  of 
small  masses  or  points  of  tenderness. 

For  the  more  definite  localization,  the  time  honored  division  into  squares, 


REGIONS  OF  THE  ABDOMEN 


21 


by  two  vertical  and  tAvo  horizontal  lines  (Fig.  28),  is  the  one  generally  fol- 
lowed in  anatomical  and  diagnostic  works.  However,  as  a  practical  working 
division  for  diagnostic  and  teaching  purposes,  this  has  been  found  decidedly 
inconvenient  and  unsatisfactory,  as  is  attested  by  the  many  attempts  of 
clinicians  to  devise  a  simple  method  of  dividing  the  surface  and  of  designat- 
ing the  various  regions. 

Failing  to  find  a  method  of  division  that  was  satisfactory  to  me,  I  devised 


Fig.  29.     Di\ision  of  the  abdomen  into  regions  by  means  of  a  circle  witti  a  two-inch  radius  and  two-inch 
horizontal  lines. 


that  shown  in  Fig.  29,  which,  so  far  as  I  know,  is  original.  The  only  lines  not 
marked  by  natural  landmarks  are  a  circle  Avith  a  two-inch  radius  about  the 
umbilicus  and  a  short  straight  line  extending  horizontally  for  two  inches 
from  each  side  of  the  circle. 

The  regions  are  designated  as  right  lower,  left  lower,  central  lower,  right 
upper,  left  upper,  central  upper,  umbilical,  and  right  and  left  lumbar  (Fig. 
'SO).  This  method  of  division  is  simple,  and  the  names  are  easily  remembered 
and  are  self-explanatory.  In  fact,  these  designations  are  the  ones  commonly 
used  in  cocversfition  among  physicians  in  describing  the  location  of  a  mass 


22 


THE  PHYSICAL  EXAMINATION 


or  area  of  tenderness.  For  example,  we  speak  of  tenderness  in  the  right  lower 
region  of  the  alxlomen,  or,  more  briefly,  in  the  ''right  lower  abdomen,"  or  in 
the  "left  lower  abdomen,"  or  in  the  "right  upper  abdomen,"  etc. 


V 


Lawer 


L-i-  I 


U}^}^r 


Uft 


Li\^eir    it'' 


^ 


Fi};.  30.     Another  ahiloiiieii  divided  with  the  circle  and  stiort  horizontal  lines,  and  siiowini,'  the  names  on 
the  primary  regions.     The  area  within  the  circle  carries  the  usual  designation,  "uuibihcal  region." 

Within  each  of  these  principal  regions  there  are  one  or  more  points  which 
are  of  special  interest.     The  special  interest  attaches  to  each  one  of  these 


TENDERNESS   IN  THE    ABDOMEN 


23 


points  because  well-defined  tenderness  limited  to   sneli  point  usually  means 
an  afiPection  of  a  particular  organ.     It  must  he  k(^pt  in  mind,  however,  that 

in  some  eases  such  point-t(^nderness  is  due  lo  ■•iii   ;i(Tcc1i()ii  of  soiik^  adjacent 


K. 


St. 


xr 


ut 
21 


T~0. 


Fig.  31.     Various  areas  of  significant  Point-tenderness.      These  are  the  areas  to.  be  investigated  during  the 
course  of  an  abdominal  examination, 


24 


THE  PHYSICAL  EXAMINATION 


organ  (as  when  inflammation  within  the  caecum  causes  tenderness  in  the 
appendix  region),  or  even  of  some  distant  organ  which  has  become  displaced 
(as  when  the  right  kidney  has  become  displaced  into  the  appendix  region). 
Again,  in  some  cases  tenderness  is  due  to  an  organic  or  functional  dis- 
turbance of  the  nerves  of  the  abdominal  wall  or  to  reflected  pain,  due  to  a 


Fig.  32.     Point  for  Kidney  Tenderness  laterally.    .  Fig.  33.     Points  for  Ividney  Tenderness  in  the  back. 


Fig.  34.  Relation  of  the  Ividney  to  the  lower 
margin  of  the  last  rib.  (Butler — Diagnostics 
of  Internal  Medicine.) 


TrN  iiig  lor  ii  ]''liiiil  \\'a\  ^^  Mcross  I  ho  iilidonu'ii. 


lesion  in  some  other  part  of  the  abdominal  cavity  or  to  some  organic  or 
functional  lesion  in  a  distant  part  of  the  body.  But  even  in  these  exceptional 
<ionditions  the  tenderness  is  usually  not  a  genuine  "point  tenderness,"  but 


AREAS  OF  POINT-TENDERNESS  25 

is  more  extensive  and  cau  be  traced  iu  some  direction  sufficiently  I'ar  to  in- 
dicate its  prol)al)le  origin. 

With  the  exceptions  above  mentioned  kept  in  mind,  the  special  areas  of 
"point  tenderness"  are  of  great  help  in  the  diii'erential  diagnosis  of  ab- 
dominal lesions. 

I  do  not  approve  of  the  method  of  naming  the  principal,  or  primary, 
regions  of  the  abdomen  from  the  significant  point-tenderness  situated  there- 
in. For  example,  to  designate  the  right  lower  abdomen  as  the  "appendiceal 
region,"  as  is  done  by^  some  authorities,  leads  only  to  confusion.  It  is  no 
more  the  appendiceal  region  than  it  is  the  caecal  region,  or  tlie  tubo-ovarian 
region,  or  the  ureteral  region.  The  term  "appendiceal  region"  should  be 
reserved  for  the  very  circumscribed  area  immediately  over  tlie  appendix, 
the  same  as  the  terms  "tubo-ovarian  region"  and  "ureteral  region"  should 
be  limited  to  the  areas  containing  those  structures.  Then,  when  we  speak  of 
tenderness  iu  the  appendiceal  region,  there  is  no  question  as  to  the  exact 
location  of  the  tenderness. 

The  principal  areas  of  significant  point-tenderness  are  shown  in  Fig.  31. 
There  are,  of  course,  also  many  areas  of  secondary  importance — of  secondary 
importance  because  tenderness  or  a  mass  therein  is  not  of  such  definite 
significance. 

After  locating  accurately  the  point  of  greatest  tenderness,  try  to  trace  the 
tenderness  in  various  directions.  This  is  especially  useful  in  cases  which  are 
doubtful,  because  the  tenderness  is  not  typically  situated  or  is  not  well  limited. 

For  example,  take  a  case  in  which  the  most  marked  point-tenderness  is 
situated  about  midway  between  the  right  tube,  the  appendix  and  the  ureter. 
It  may  be  due,  among  other  things,  to  disease  of  the  tube  or  ovary,  or  of  the 
ureter  or  caecum,  or  of  the  appendix  or  small  intestine,  or  of  tJie  peritoneum. 
Determiue  if  well-marked  tenderness  can  be  traced  down  toward  Poupart's 
ligament  and  the  tube.  If  the  tenderness  does  not  extend  in  that  direction, 
it  is  probably  not  due  to  trouble  about  the  tube  or  ovary.  Then  try  to  trace 
it  to  the  ureter  and  along  the  ureter  downward  toward  tlie  l)ladder  and 
upward  toAvard  the  kidney.  Determine  also  if  it  spreads  over  the  caecum 
and  extends  up  along  the  ascending  colon,  as  it  is  likely  to  do  when  caused 
by  inflammation  of  the  large  bowel.  Determine  if  it  extends  through  the  abdo- 
men generally,  including  the  umbilical  region  and  beyond. 

If  it  does  not  extend  in  any  one  of  the  directions  mentioned,  but  is  strictly 
limited  to  the  point  designated,  it  is  probably  due  to  appendix  trouble,  Avhich 
probable  diagnosis  must  be  strengthened  or  weakened,  as  the  case  may  be,  by 
other  signs  present  and  by  the  history  of  the  trouble. 

In  those  cases  in  which  there  is  a  question  as  1o  Avhether  or  not  (he  tender- 
ness is  due  to  trouble  in  the  ureter,  particularly  where  the  tenderness  extends 
over  the  w^hole  right  lower  or  left  lower  abdomen,  or  is  so  acute  as  to  prevent 
the  deep  palpation  necessary  to  accurate  localization,  palpation  of  the  lumbar 
region  laterally  and  posteriorly  is  of  much  assistance  in  the  differential  diag- 


26 


THE  PHYSICAL  EXAMINATION 


nosis.  Well-marked  ureteritis  is  usually  accompanied  by  pyelitis  and  kidney 
tenderness.  In  such  a  case  there  is  distinct  tenderness  over  the  kidney  later- 
ally (Fig.  32)  and  also  posteriorly  (Figs.  33,  34). 

Mass  in  the  Abdomen. 

"When  a  mass  is  discovered,  determine  as  far  as  possible  its  position,  size, 
shape,  consistency,  tenderness,  mobility  and  attachments. 

The  position  of  a  mass  indicates  in  a  general  way  the  organ  or  group  of 


Fig.  oG.     Differentiating  a  Fat-wave  from  a  Fluid-wave.     Tlie  Fat-wave  is  stopped  by  tlie  pressure  in  the 
median  line 


organs  from  which  it  arises.     Keep  in  mind,  however,  that  it  may  be  due  to 
some  adjacent  organ,  or  even  some  distant  organ  displaced  into  that  region. 

The  size  and  shape  of  a  mass  is  determined  by  ascertaining  its  length, 
breadth,  thickness  and  general  contour.  The  length  or  height  of  a  tumor  pro- 
jecting up  from  the  pelvis  is  usually  designated  as  so  many  inches  or  centi- 
meters above  the  symphysis  pubic,  or  ])elow  tbe  uml)ilicus  or  aliove  the 
lunbilicus.  The  breadth  may  be  given  approximately  in  inelies  or  centimeters, 
stating  at  the  same  time  whether  or  not  the  mass  is  situated  symmetrically 
on  either  side  of  the  median  line,  or  the  mass  may  be  referred  to  as  filling 
the  pelvis  from  side  to  side  or  as  filling  the  abdomen.  It  is  sometimes  difficult 
to  convey  a  satisfactory  idea  of  the  general  contour  of  a  mass  by  a  detailed 


OTHER  POINTS  IN   PALPATION 


27 


doscriplion,  when  it  may  be  V(ny  ([iiickly  convL-ycd  l)y  referring  to  some  well- 
known  object— e.  g.,  an  egg,  a  lemon,  a  kidney  or  an  liour-glass.  Tlie  con- 
sistency of  a  mass  should  be  carefully  determined.  Is  it  uniformly  solid  or 
does  il  i)n'scii1  hai'd  nodules,  or  docs  it  contain  fluid?  If  the  mass  contains  a 
collection  of  fluid  of  sufficient  size,  there  may  be  elicited  that  peculiar  sensa- 
tion known  as  fluctuation,  tiie  recognition  of  which  is  one  of  the  first  lessons 
in  surgical  work.  If  tlicre  is  a  large  collection  of  fluid,  as  in  a  case  of  marked 
ascites,  a  fluid  wave,  started  by  tapping  on  one  side  of  the  abdomen,  may  be 
felt  by  the  other  hand  applied  to  the  other  side  (Fig  35).  A  somewhat  similar 
Avave  may  be  caused,  also,  by  a  thick  layer  of  subcutaneous  fat  (fat  wave).  In 
such  a  case,  however,  if  an  assistant  press  lightly  in  the  median  line  with  the 
ulnar  edge  of  the  hand,  the  fat  wave  will  stop  at  the  line  of  pressure  (Fig.  36). 


^ 


Fig.  37.      Attempting  to  Displace  a  mass  upward  in  order  to  determine  if  it  has  a  pelvic  attachment. 


A  distinct  fluid  wave  may  be  obtained  in  any  large  collection  of  fluid  with 
a  comparatively  thin  wall.  It  is  present  in  well-marked  ascites,  in  unilocular 
cysts  and  in  multilocular  cysts  with  one  or  more  large  caA^ities.  Occasionally 
the  fact  that  there  are  different  large  cavities  in  the  cyst  may  be  surmised  by 
a  distinct  difference  in  the  fluid  wave  as  obtained  through  different  parts  of 
the  cyst.  In  a  cyst  with  small  cavities  no  fluid  wave  is  obtained,  as  there  is 
not  a  large  enough  single  cavity,  although  fluctuation  may  be  as  clear  as  in 
a  single  large  cyst.  Also,  in  a  cyst  Avith  thick  gelatinous  contents  a  fluid  wave 
may  not  be  obtained. 

The  tenderness  of  a  mass  as  determined  by  palpation  is  of  much  importance 
in  differential  diagnosis.  In  acute  inflammation  (as  in  acute  salpingitis  or 
peritonitis),  or  in  acute  irritation  (as  in  hemorrhage  from  tul)al  pregnancy), 
the  tenderness  is  very  marked.  On  the  other  hand,  in  uncomplicated  ovarian 
or  uterine  tumors,  tenderness  is  slight. 

The  mobility  and  attachments  of  a  mass  are  determined  by  attempting  to 
move  the  mass  in  different  directions.   The  fingers  are  worked  in  deeply  about 


ZO  THE  PHYSICAL  EXAMINATION 

the  mass  at  various  points,  and  it  is  determined  just  "what  part  may  be  easily 
displaced  and  what  part  is  fixed  (Fig.  37).  The  fixed  point  of  a  mass  usually 
indicates  its  point  of  origin — i.  e.,  the  organ  involved.  The  presence  or  absence 
of  mobility  helps  to  determine  whether  or  not  the  mass  is  bound  down  by 
inflammatory  exudate  or  is  retroperitoneal,  or  is  in  the  abdominal  wall. 

Occasionally  a  mass  is  not  mobile  because  it  is  so  large  that  it  fills  the  ab- 
dominal cavity.  Some  retroperitoneal  masses  (particularly  kidney  tumors) 
present  marked  mobility  in  certain  directions. 

Fetal   Movement,    Uterine   Contraction,    Friction   Rub. 

In  late  pregnancy,  fetal  movement,  caused  by  the  fetus  changing  position  or 
kicking,  may  not  infrequently  be  felt.  Dipping  the  hands  in  cold  water  and 
then  laying  them  flat  over  the  uterus  may  cause  the  fetus  to  move. 

The  absence  of  fetal  movements  is  of  no  diagnostic  significance,  but  the 
presence  of  them  is  of  course  certain  evidence  of  existing  pregnancy  and  con- 
sequently well  worth  trjang  for  in  a  doubtful  ease. 

The  same  may  be  said  of  the  intermittent  contraction  and  relaxation  of  the 
pregnant  uterus.  In  some  cases  alternate  hardening  and  softening  of  the 
uterus  may  be  very  distinct,  and  is  positive  evidence  of  the  character  of  the 
mass  under  the  hands. 

A  friction  rub  may  sometimes  be  felt  in  a  case  of  active  peritonitis,  particu- 
larly in  the  local  plastic  or  irritatiA'e  peritonitis  that  not  infrequently  takes 
place  when  a  tumor  lies  against  the  abdominal  wall.  The  hand  is  pressed  over 
the  mass  during  forced  respiration.  Occasionally  the  friction  rub  may  be 
obtained  over  the  liver  or  spleen  when  there  is  a  local  peritonitis  there. 

PERCUSSION   OF   ABDOMEN. 

Areas  of  Dullness. 

Percussion  over  the  abdomen  serves  to  confirm  the  information  obtained  by 
palpation,  and  also  brings  out  some  new  facts — for  example,  by  outlining 
accurately  the  area  of  dullness  it  shows  at  what  portion  of  the  abdominal  wall 
the  tumor  or  fluid  lies  against  the  wall,  and  at  what  portion  there  is  interven- 
ing intestine.  It  shows  also  whether  the  mass  or  fluid  changes  relations  when 
the  patient  changes  position.  In  a  ventral  hernia  (intestinal)  it  shows  that 
the  large  mass,  which  might  be  taken  for  a  tumor  or  inflammatory  mass,  is 
resonant — i.  e.,  it  contains  air,  and  therefore  must,  under  ordinary  circuin- 
stauces,  contain  intestine. 

The  use  of  superficial  and  deep  percussion  in  succession  may  give  valuable 
information  in  some  cases.  Ordinary  percussion  (Fig.  38 "I  is  moderately  light 
and  superficial,  and  gives  resonance  over  all  the  normal  abdomen,  except 
where  the  liver  lies  against  the  Avail.  In  marked  obesity,  hoAvever,  superficial 
percussion  is  likely  to  give  only  dullness  over  all  the  abdomen,  Avhile  deep  per- 


PERCUSSION    AND  AUSCULTATION 


29 


eussion   (a  hard  percussion  stroke  acrjiinst  tlie  fiiif^'cr  i)r('ssc(l  in  dcr-ply Fi{^. 

39)  gives  resonant- e. 

A  tumor  of  the  wall  or  of  the  omentum  ordinarily  gives  dullness  in  lij^lit 
percussion  and  resonance  in  deep  percussion. 


Fig.  38.    Ordinary   Percussion,   which  is  usually 
rather  superficial. 


Fig.  .39.  Deep  Percussion.  Notice  how  the  left 
index  finger  is  pressed  into  the  abdomen,  so  as  to 
thin  out  the  wall  and  get  closer  to  deep  structiire.s. 


Endeavor  to  get  definitely  in  mind  exactly  the  reason  for  the  dullness  or 
resonance  found  in  a  particular  case,  and  then  its  diagnostic  significance  will 
be  clear. 

AUSCULTATION. 
Fetal  Heart  Sounds,  Vascular  Murmur. 

Auscultation,  either  by  the  ear  direct  (a  sheet  intervening)  or  by  the  stetho- 
scope, should  always  be  employed  when  there  could  be  any  confusion  with 
advanced  pregnancy,  as  in  a  case  of  large  ovarian  tumor  or  large  fibroid.  The 
fetal  heart  sounds  are  the  only  sounds  pathognomonic  of  pregnancy.  The 
placental  murmur  may  be  simulated  by  the  large  vessels  of  a  tumor.  The  ab- 
sence of  fetal  heart  sounds  does  not  exclude  pregnancy,  for  even  in  cases  of 
normal  pregnancy  they  cannot  always  be  heard.  Auscultation  should  be  em- 
ployed also  in  obscure  cases  of  pain  in  the  abdomen,  particularly  if  accom- 
panied by  pulsation.  The  pain  may  be  due  to  an  aneurism  of  the  abdominal 
aorta,  which  occasionally  runs  its  course  unrecognized  until  rupture  and  sud- 
den death.  In  auscultation  for  aneurismal  murmur  with  a  stethoscope,  be 
careful  that  the  abdominal  wall  is  not  pressed  firmly  against  the  aorta  with 
the  stethoscope,  for  such  pressure  will  cause  a  murmur  in  a  normal  vessel 


30 


THE  PHYSICAL  EXAMINATION 


Excessive  gurgling  in  the  intestines  may  be  heard  in  most  intestinal  diseases 
accompanied  with  tympanites.  It  is  heard  particularly  in  the  region  of  the 
ileocecal  valve  or  about  a  partial  obstruction  or  over  a  loop  of  bowel  in  peris- 
taltic movement.  Gurgling  over  a  large  mass  indicates  that  one  or  more  intes- 
tinal coils  are  between  it  and  the  abdominal  wall.  This  intestine  may  b(}  in 
front  because  the  mass  is  retroperitoneal  or  because  an  intestinal  coil  is 
adherent  over  the  mass,  or  because  the  mass  is  made  up  partly  or  wholly  of 
adherent  intestinal  coils. 

A  friction  sound  may  occasionally  be  heard  in  local  peritonitis,  particularly 
over  the  areas  of  fresh  plastic  peritonitis  or  over  a  tumor. 

MENSURATION    OF   ABDOMEN. 

Measure  the  abdomen  when  it  is  very  large  or  when  there  is  a  growing  tumor, 
or  when  for  other  reason  it  may  be  desirable  to  know  exactly  any  difference 
in  size  some  weeks  or  months  hence,  or  when  it  is  desired  to  speak  with  accu- 
racy  concerning  the  size  of  the  abdomen  in  the  case  of  a  large  growth. 

The  measurements  are  made  with  the  ordinary  tape-line.    When  measuring 


Fig.  40.     Showing  tlie  lines  for  Mensunition. 


EXAMINATION  OP  THE  EXTERNAL  GENITALS  3X 

a  patient,  take  enougli  incasureiiR'nt.s  to  makt;  an  accuratt;  record.  Measure- 
ments along  tlie  Hues  sliown  in  Fig.  40  will  show  variations  witii  a  large  growth 
in  any  part  oi*  the  peritoneal  eavity.     They  are  as  follows: 

1.  From  nuihilieus  to  sternal  noteh. 

2.  From  nmbilieus  to  puhes. 

3.  From  uuibiliens  to  right  anterior  superior  iliae  spine. 

4.  From  nmbilieus  to  left  anterior  superior  iliae  spine. 

5.  Circumference  of  body  at  level  of  umbilicus. 

6.  Circumference  of  body  3  inches  above  umbilicus. 

7.  Circumference  of  body  3  inches  below  umbilicus. 

EXAMINATION  OF  EXTERNAL   GENITALS  AND  ADJACENT  STRUC- 
TURES. 

If  the  patient  complains  of  irritation  about  the  external  genitals,  or  of  itch- 
ing or  burning,  or  of  frequent  or  painful  urination,  or  of  sores  or  swelling,  or 
discharge,  the  parts  should  be  inspected  in  a  good  light.  For  this  examination, 
as  the  patient  is  lying  on  the  table,  the  lower  extremities  are  covered  with  a 
sheet,  the  skirts  are  pushed  above  the  knees  and  out  of  the  way,  and  the  hips 
are  brought  to  the  end  of  the  table,  as  shown  in  Fig.  41. 

A  general  inspection  is  then  given  the  parts,  to  ascertain  if  they  are  prac- 
tically normal  (Figs.  42,  43)  or  if  there  is  marked  abnormality.   The  labia  are 
then  separated,  to  expose  the  vestibule  and  urethral  and  vaginal  openings, 
and  also  the  openings  of  the  ducts  of  the  vulvo-vaginal  glands  (Figs.  44,  45). 
By  examination  determine  if  any  of  the  following  conditions  are  present : 
Discharge — Muco-epithelial,  Muco-purulent,  Purulent,  Bloody ,Watery. 
Inflammation — Gonorrhoeal  or  otherwise. 

Ulcer — Simple,  Chancroidal,  Syphilitic,  Tubercular,  Malignant. 
Swelling — Inflammatory,     Stasis    Infiltration,     Oedema,    Hematoma, 

Hernia,  Cyst. 
New  Growth — Condyloma,  Urethral  Caruncle,  Lipoma,  Fibroma,  :\ra- 

lignant  Growth. 
Malformation — Adhesions  of  Labia,  Pseudo-hermaphroditism. 

Determine  also  the 

Condition  of  Hymen — Intact,  Lacerated,  Destroyed. 
Condition  of  Perineum — Normal,  Lacerated  (wide  opening,  vaginal 
w^alls  visible,  shallow  perineum,  scar  tissue,  fistula). 

DISCHARGE  ABOUT  EXTERNAL  GENITALS. 

Muco-epithelial,   Muco-purulent,   Purulent,   Bloody,   Watery. 

Muco-epithelial   Discharge    (normal).     The  normal  mucus   secretion   from 

the  cervix  moistens  and  macerates  the  vaginal  epithelium.    The  mixture  of  this 

cervical  mucus  and  vaginal  epithelium  appears  at  the  external  genitals  as  a 

white    crumbly  discharge.    Usually  it  is  hardly  noticeable,  only  just  enough 


32 


THE  PHYSICAL  EXAMINATION 


to  keep  the  parts  normally  moist.  At  the  menstrual  periods,  and  under  other 
conditions  favoring  pelvic  congestion,  it  may  increase  so  as  to  be  somewhat 
annoying  to  1  e  patient,  though  hardly  of  pathological  importance. 

Muco-purulent  Discharge.  AA^hen  there  is  inflammation  or  persistent  con- 
gestion in  the  uterus,  the  mucus  secretion  is  much  increased,  and  there  are 
thrown  out,  at  the  same  time  and  for  the  same  cause,  many  leukocytes,  which 


Fig.  41.     Patient  in  position  for  Examination  of  External  Genitals  and  adjacent  structure.s. 


mix  with  the  mucus,  giving  it  somewhat  of  a  purulent  character,  the  promi- 
nence of  the  purulent  feature  depending  on  the  amount  of  this  admixture  of 
dead  leukocytes.  If  it  contains  enough  mucus  to  be  noticeable,  the  discharge 
is  sticky  and  stringy,  and  may' be  drawn  out  into  long  threads. 

Purulent  discharge  presents  the  appearance  of  pus,  as  from  an  abscess  or 
inflamed  surface,  either  thin  pus  or  thick  yellow  pus.  Determine  just  where 
this  comes  from — i.  e.,  whether  from  the  urethra  or  vulvo-vaginal  gland,  or 
inflamed  surfaces  on  the  external  genitals  or  from  the  vagina. 


DISCHARGE  ABOUT  THE   EXTERNAL  GENITALS 


33 


Dip  the  tip  of  a  cotton-wrapped  applicator  in  tliis  j)iinilciit  discliarge  and 
spread  some  on  a  microscopic  slide. 

If  possible,  secure  some  discharge  from  the  urethra  or  vulv  ^-vaginal  gland, 
for  the  pus  from  these  situations  is  much  more  satisfactory  for  micros('0])i(', 
examination  than  the  mixed  vulvar  or  vaginal  discharge. 

To  secure  urethral  pus,  separate  the  lahia,  cleanse  the  meatus,  and  compress 
the  internal  end  of  the  urethra  by  pressure  against  the  anterior  vaginal  wall 
with  the  tip  of  the  index  finger.  Tlien,  still  maintaining  the  pressure,  di-aw 
the  tip  of  the  finger  along  the  urethra  towai-d  1he  meatus  (Fig.  4(1 ).  'I'his 
brings  the  uretliral  pus  to  tlie  meatus  (Fig.  47). 


Fig.  42.  External  Genitals.  1.  Mons  veneris.  2.  Left  Labium  Majus,  drawn  aside.  .3.  Clitoris.  4. 
Left  Labium  Minus,  slightly  larger  than  the  a,verage.  5.  Vestibule.  6.  Urethra.  7.  Duct  of  Vulvo-Naginal 
Gland.  8.  Vaginal  Entrance.  9.  Remains  of  Hymen.  10.  Fourchette.  11.  Anus.  {ByfoT(\—Mnnual  of 
Gynecology.) 


Chronic  inflammation  in  the  urethra  is  likely  to  be  situated  in  Skene's 
glands,  and  in  such  a  case  some  pus  may  be  pressed  from  these  small  glands 
by  compressing  the  urethra  (by  pressure  through  anterior  vaginal  wall)  just 
back  of  the  meatus.  In  some  cases,  particularly  in  multipara,  the  uretliral 
mucosa  pouts  out,  so  that  by  careful  examination  the  orifice  of  one  or  both 
of  Skene's  glands  may  be  seen.  Fig.  48  shows  such  a  gland-opening  (left 
side)  and  also  a  drop  of  pus  which  has  been  pressed  from  the  gland  on  the 
right  side. 

The  vulvo-vaginal  glands  (Bartholin's  glands)  are  situated  symmetrically 
on  either  side  of  the  vaginal  opening,  as  shown  in  Fig.  49.  The  opening 
of  the  duct  of  the  gland  of  each  side  is  situated  laterally,  just  in  front  of 
the  remnants  of  the  hymen  and  a  little  below  the  middle  of  the  lateral  margin 


34 


THE  PHYSICAL  EXAMINATION 


of  the  vaginal  opening.  Draw  aside  the  labia  in  this  situation  and  look  for 
the  opening  of  the  gland,  and  determine  whether  or  not  the  opening  is  red- 
dened and  if  there  is  any  discharge  from  it  (Fig.  50). 

To  examine  either  vulvo-vaginal  gland,  to  determine  if  there  is  any  thick- 
ening or  tenderness  from  inflammation,  or  if  pus  can  be  squeezed  from  it,  grasp 
the  region  of  the  gland  between  the  index  finger  in  the  vagina  and  the  thumb 
outside,  as  shown  in  Fig.  51. 

When  securing  secretion  for  microscopic  examination,  it  is  well  to  take 
discharge  from  different  localities,  making  the  spread  with  the  applicator-tip 


Fig.  43.     Practically  Normal  External  Genitals— multipara,  labia  together.     The  corrugations  of  the  tebia 
minora  can  hardly  be  called  abnormal. 


in  the  form  of  different  letters  for  different  regions — for  example,  U  (urethra), 
V  (vagina),  C  (cervix).  If  the  specimens  are  to  be  sent  to  a  laboratory,  stick 
a  small  label  to  each  slide,  and  write  on  it  the  date,  the  patient's  initials,  and 
the  exact  locality  from  which  it  was  taken.  In  a  doubtful  case  of  uretliritis, 
in  which  no  secretion  can  be  secured  at  the  first  examination,  direct  tlie  pa 
tient  to  pass  no  urine  for  two  or  three  hours  before  the  next  examination. 

Bloody  Discharg-e.  The  discharge  is  red  or  l)rown,  tlie  intensity  of  tlie  color 
depending,  of  course,  upon  the  amount  of  blood.  It  varies  all  the  way  from 
a  slight  reddish  or-  brownish  tinge,   hardly  noticeable,   to   practically  pure 


INFLAMMATION  ABOUT  THE  EXTERNAL  GENITALS 


35 


blood  or  clots.  The  blood  may  be  mixed  with  any  of  the  other  pathological 
discharges — muco-purulent,  purulent  or  watery.  The  causes  of  blood  in  the 
vaginal  discharge  are  enumerated  in  chapter  II  (page  179). 

Watery  Discharge.  A  portion  of  the  discharge  appears  like  water.  This 
may  be  associated  with  the  normal  muco-epithelial  discharge  or  with  a  muco- 
purulent or  purulent  discharge.  The  most  common  cause  of  a  watery  dis- 
charge is  the   decomposition  of  a  malignant   tumor-mass   in   tlie   vagina   or 


Fig.  44.     Labia  separated,  to  expose  upper  part 
of  vestibule. 


Fig.  45.     Labia  separated,  to  expose  lower  part 
of  vestibule. 


Uterus,  giving  the  characteristic  watery,  foul-smelling  discliarge  of  advanced 
cancer  or  sloughing  fibroid. 

INFLAMMATION  ABOUT  EXTERNAL  GENITALS. 

Gonorrhoeal  or  Otherwise. 

Inflammation  is  indicated  by  redness  and  tenderness,  either  diffused  or  in 
spots.  It  is  usually  accompanied  by  smarting  or  burning  on  urination.  The 
smarting  on  urination  and  the  increased  frequency  of  urination  are  most 
marked  when  the  urethra  is  involved. 


36 


THE   PHYSICAL  EXAMINATION 


Fig.  46.     Method  of  pressing  pus  from  the  depth  Fig.  47.     Appearance    of    pus    at    the    i:rethral 

of  the  urethra  to  the  meatus.  opening. 


Fig.  48.  Shght  ever- 
sion  of  urethral  mucosa, 
.so  that  openings  of 
Skene's  glands  come 
into  view.  On  left  .side 
the  gland  openin.g  is 
seen.  On  right  .side  a 
drop  of  pus  lias  been 
scjueezed  from  the  gland 
and  partially  obscures 
the  field.  (Kelly — Oper- 
ative Gynecology.) 


Fig.  41).  Viiivo-vaginal  gland  (D) 
duct  (C)  of  right  -side.  (Byfonl,  : 
Huguier. — Manual  of  Gynccolngij.) 


and 
ficr 


ULCERS,  SWELLINGS,  NEW  GROWTHS 


87 


ULCP]R  ABOUT  EXTERNAL  (iENITALS. 

Simple,  Chancroidal,  Syphilitic,  Tubercular,  Malignant. 

If  au  ulcer  is  found,  determiue  its  position,  .size,  shape,  consistency  (edge 
and  underlying  tissues),  tenderness  and  mobility  (wliether  fixed  to  under- 
lying deep  structures  or  freely  movable).  Determine  also  the  character  of  the 
discharge  from  it,  and  Avhether  it  bleeds  readily  on  touching.  Notice  wliether 
the  base  is  made  of  regular  granulation  tissue  or  has  yellow  dots  scattered 


Fig.  50.     Appearance  of  pus  about  the    opening  of 
the  left  vulvo-vaginal  gland. 


Fig.  51.  Palpating  the  left  vulvo-vaginal 
gland,  to  determine  if  there  is  tliickening  or 
tenderness,  or  if  pus  can  be  pressed  from  it. 


in  it,  or  is  filled  with  a  slough.  Examine  also  the  edges— do  they  slope  from 
within  outward,  as  in  an  ordinary  ulcer  when  healing,  or  are  they  sharp-cut 
and  perpendicular,  or  undermined  as  in  a  rapidly  spreading  chancroid?  Is 
there  a  red  acute-inflammatory  zone  about  the  ulcer  or  is  there  a  wide  area 
of  chronic  infiltration  (chronic  inflammation,  malignant)  ?  Is  there  only  a 
single  sore  or  are  there  several?  Are  the  inguinal  glands  affected?  If  so,  in 
w^hat  way?  Is  there  any  other  condition  indicating  the  cause  and  character 
of  the  ulcer?  For  the  differential  diagnosis  of  the  various  kinds  of  ulcer  see 
the  consideration  of  ulcers  in  chapters  II  and  IV. 


38  THE  PHYSICAL  EXAMINATION 

SWELLING  ABOUT  EXTERNAL  GENITALS. 
Inflammation,  Stasis  Infiltration,  Oedema,  Hematoma,  Hernia,  Cyst. 

Swelling  may  be  inflammatory  (as  in  acute  oedema  or  abscess),  or  obstruct- 
ive (as  in  oedema  from  obstruction  by  heart  or  liver  disease  or  from  tumor  in 
abdomen  or  pelvis).  There  may  be  obstructive  oedema  and  infiltration  from 
scar  tissue  about  the  pubic  arch  (stasis  hypertrophy),  or  oedema  and  infiltra- 
tion from  obstruction  of  vessels  by  filaria  (elephantiasis). 

The  swelling  may  be  a  pudendal  hernia,  which  originates  either  as  an 
inguinal  or  a  vaginal  hernia. 

The  swelling  may  be  a  retention  cyst,  the  most  common  of  which  is  cyst 
of  the  vulvo-vaginal  gland.  For  complete  enumeration  and  differential  diag- 
nosis of  vulvar  swellings  see  chapter  II  (page  181)  and  chapter  IV  (page  419). 

NEW  GROWTHS  ABOUT  EXTERNAL  GENITALS. 
Condyloma,   Urethral  Caruncle,   Lipoma,   Fibroma,   Malignant  Growths. 

Condylomata  are  small  papillomata,  from  pin-head  to  hazel-nut  size,  that 
appear  about  the  labia  and  meatus  as  the  result  of  chronic  irritation.  They 
are  seen  most  frequently  in  gonorrhoea  and  secondary  syphilis.  Occasionally 
condylomatous  growths  unite  to  form  a  large  mass,  as  shown  in  chapter  II 
(page  198). 

Caruncle  is  a  papilloma  occurring  about  the  meatus.  Usually  it  is  ex- 
tremely tender. 

Fibroma,  lipoma  and  other  non-malignant  tumors  are  rare,  although  they  do 
occur  occasionally,  fibroma  being  the  most  frequent. 

Malignant  growths  in  this  situation  very  rapidly  reach  the  stage  at  which 
complete  extirpation  is  impossible,  hence  the  importance  of  recognizing  the 
condition  very  early. 

CONDITION  OF  HYMEN. 

Intact,  Lacerated,  Destroyed. 

Does  the  hymen  present  the  virginal  appearance,  or  is  it  lax  and  the  open- 
ing large,  as  from  sexual  intercourse,  or  is  it  destroyed  from  labor,  being 
represented  by  only  a  few  remnants  (carunculae  myrtiformes)  ? 

CONDITION  OF  PERINEUM. 
Wide  Opening,  Vaginal  Walls  Visible,  Shallow  Perineum,  Scar  Tissue,  Fistula. 

For  the  detailed  diagnosis  of  lacerations  see  chapter  II  (pages  186,  474). 

VAGINAL  EXAMINATION  (DIGITAL). 

In  the  vaginal  examination,  or  digital  examination,  as  it  is  frequently 
designated,  one  or  two  fingers  are  introduced  into  the  vagina  and  tlie  struc- 
tures within  reach  are  palpated.     In  this  way  valuable  information  may  be 


THE  VAGINAL  EXAMINATION  39 

obtained  iu  certain  eases.    It  is  also  a    preliminary    step    to  the  important 
vagino-abdominal  or  biiuaniial  examination,  to  he.  taken  np  later. 

Method  of  Examination. 

U.se  two  fingers  for  the  vaginal  palpation  where  the  size  of  the  vaginal 
opening  will  permit.  A  much  deeper  and  more  accurate  examination  can  be 
made  with  both  the  index  and  middle  finger,  than  Avith  the  index  finger 
alone.  Ordinarily  in  the  examination  of  a  married  woman,  even  one  wlio  lias 
had  no  children,  two  fingers  may  be  introduced  without  difficulty,  provided  the 
fingers  are  well  lubricated  and  care  is  taken  to  cause  no  pain. 

It  is  important  also  to  separate  the  labia  with  the  fingers  of  the  other  hand 
while  the  examining  fingers  are  being  introduced,  for,  if  the  hair  and  labia 
are  allowed  to  roll  in  with  the  examining  fingers,  much  pain  is  caused  the 
patient  and  the  opening  is  considerably  narrowed. 

In  eases  where  there  is  any  venereal  disease  or  purulent  discharge,  and  also 
in  cases  where  it  is  uncertain  whether  or  not  such  will  be  encountered,  rubber 
gloves  are  convenient  and  advisable.  When  intact,  they  give  complete  pro- 
tection against  syphilis  or  other  infection  wdiich  might  come  through  an  un- 
noticed abrasion  about  the  fingers.  Another  advantage  is  that  less  scrubbing 
of  the  hands  is  needed  after  the  examination.  Frequent  severe  scrubbing  of 
the  hands  and  the  use  of  strong  antiseptic  solutions  keep  the  skin  in  an 
irritated,  unhealthy  condition,  particularly  in  cold  weather.  When  rubber 
gloves  are  used,  all  the  infectious  material  is  removed  with  the  gloves,  which 
are  boiled  and  are  then  ready  for  the  next  examination. 

Fig.  52  shows  the  position  of  the  fingers  ordinarily  preferable  in  the  vaginal 
and  bimanual  examinations.  Fig.  53  shows  the  hand  gloved  and  ready  for 
the  vaginal  examination.  Fig.  54  show^s  the  disposition  of  the  outside  fingers 
and  the  thumb  as  the  examination  is  being  made.  The  third  and  fourth 
fingers  are  folded  into  the  palm  of  the  hand  as  far  as  possible,  and  care  is 
taken  to  maintain  extension  of  the  thumb,  so  that  it  does  not  infringe  upon 
the  genitals  in  the  region  of  the  clitoris.  For  the  same  reason,  in  the  deep 
internal  palpation  the  wrist  should  be  dropped  low  and  the  examining  fingers 
directed  upward,  so  as  to  throw  the  thumb  away  from  the  genitals.  In  the 
very  deep  palpation  in  the  sides  of  the  pelvis,  when  the  thumb  is  necessarily 
in  the  w^ay,  it  should  be  turned  far  to  one  side  or  the  other,  and  thus  kept 
from  contact  with  the  sensitive  areas  (Fig.  80).  In  regard  to  the  disposition 
of  the  third  and  fourth  fingers,  it  is  advantageous  in  some  cases,  particularly 
in  very  stout  patients,  to  extend  these  fingers  along  in  the  internatal  fold, 
as  showm  in  Fig.  64.  In  these  exceptional  cases  this  permits  deeper  penetra- 
tion of  the  examining  fingers. 

In  beginning  the  examination,  as  the  examining  fingers  are  being  intro- 
duced, there  is  frequently  a  tendency  on  the  part  of  the  patient,  who  is 
nervous  for  fear  of  pain  or  uncertain  as  to  Avhether  there  will  be  pain,  to 
contract  the  muscles  of   the  pelvic  floor  and  thus  interfere  with  the  vaginal 


40 


THE  PHYSICAL  EXAMINATION 


Fig.  52.     Position  of  the  fingers  for  the  vaginal  and  vagino-abdominal  examinations. 


Fig.  53.     Same  hand,  gloved  and  ready  for  the  examination. 


WHAT  STRUCTURES  TO  PALPATE 


41 


examination.  In  such  a  ease,  if  one  finger  be  introduced  a  short  distance  and 
steady  pressure  backward  be  made  against  the  muscle  (Fig.  92),  it  sh)wly 
relaxes  and  the  second  finger  may  be  introduced  beside  tlic  first.  Remciid)er, 
tliat  to  obtain  more  space  at  the  vaginal  orifice,  eillicr  in  diuii;,!  examination 
or  in  introducing  a  speculum,  always  press  downward  against  the  pelvic 
sling.  Above  and  to  the  sides  of  the  opening  is  the  bony  arch  (Fig.  55),  and 
if  an  attempt  is  made  to  overcome  the  resistance  by  direct  forward  pressure, 
without  depressing  tlie  perineum,  the  soft  tissues  aliove  are  pinched  between 
tlie  finger  or  instrument  and  the  bony  arch,  causing  the  patient  pain  and  in- 
creasing the  muscular  resistance. 
In  a  woman  who  has  borne  children  the  opening  usually  admits  the  two 


Fig.  .54.     The  gloved  hand  making  the  vaginal  examination.     The  thumb  is  held  awuy  from  the  geiiitaLs, 
and  the  third  and  fourth  fingers  are  folded  into  the  palm. 


fingers  somewhat  easier,  and  the  temporary  muscular  resistance  above  men- 
tioned is  seldom  encountered. 

What  Structures  to  Palpate. 

With  one  or  two  fingers,  w^ell  lubricated  and  introduced  into  the  vagina, 
palpate  the  following  structures: 

Vaginal  Walls — Roughness,  Tenderness,  Discharge,  Induration,  Swell- 
ing, Stricture. 
Base  of  Bladder — Tenderness,  Induration. 
Urethra — Tenderness,  Induration,  Discharge. 
Vulvo-vaginal  Glands — Tenderness,  Induration,  Discharge,  Red  Spot. 


42  THE  PHYSICAL  EXAMINATION 

/Size  of  opening, 

\  Kesistance  to  backward  pressure, 

Pelvic  Floor     /  Protrusion  of  vaginal  walls, 

Scars  and  distortions, 

Thickness  of  perineum. 

Rectum — Tenderness,  Induration,  Hemorrhoids,  Fistula,  Fissure. 

/  Position, 

t  Size  and  shape, 

1  Consistency, 

„       .     TTo.     •     /  Tenderness, 
Cervix  Uteri    (  ^r  x,^^•^ 
\  Mobility, 

I  Direction  of  canal, 

f  Laceration  and  Eversion  of  Lips, 

\  Size  and  shape  of  External  Os. 

Pericervical  Tissues — Tenderness,  Induration. 

VAGINAL  WALLS. 
Roughness,  Tenderness,  Induration,  Swelling,  Stricture. 

In  acute  vaginitis  and  in  some  cases  of  chronic  vaginitis  the  surfaces  within 
the  vagina  have  a  rough,  granular  feel  and  are  tender  on  pressure.  An 
astringent  douche — for  example,  a  bichloride  douche,  or  one  containing  zinc 
sulphate  or  tannic  acid  or  alum — will  cause  a  similar  roughness.  But  if  the 
vagina  is  both  rough  and  tender,  it  is  almost  certainly  inflamed,  providing 
the  tenderness  is  not  due  to  some  peri-vaginal  trouble.  Of  course,  the  diag- 
nosis of  vaginitis  does  not  depend  on  this  alone,  but  is  aided  by  facts  deter- 
mined in  the  speculum  examination,  and  also  by  the  history  of  the  case. 

When  discharge  is  felt  in  the  vagina,  the  assumption  is  that  it  comes  from 
the  uterus  unless  there  are  indications  of  inflammation  in  the  vagina.  If  the 
vagina  is  roughened  and  tender,  the  discharge  probably  originates  there. 
Whether  or  not  it  really  does  originate  there,  is  determined  in  the  speculum 
examination. 

Induration,  or  a  hard  place  felt  at  some  part  of  the  vaginal  wall,  may  be 
due  to  infiltration  of  the  wall  itself  (inflammation,  scar  tissue,  small  cyst,  ma- 
lignant disease)  or  to  some  trouble  back  of  the  wall. 

A  swelling  or  mass  in  the  vaginal  wall  or  bulging  into  the  vagina  from  any 
direction  may  be  due  to  any  one  of  a  number  of  conditions  which  are  men- 
tioned in  detail  in  chapter  II  (page  189). 

A  stricture  (narrowing)  or  atresia  (occlusion)  of  the  vaginal  canal  may  be 
a  congenital  malformation  or  may  be  an  acquired  condition  resulting  from 
injuries,  in  labor  or  otherwise,  or  from  severe  or  protracted  inflammation,  as 
in  the  adhesive  or  obliterative  vaginitis  seen  frequently  in  aged  patients. 
The  narroAving  of  the  canal  may  be  due  also  to  pressure  of  a  tumor  or  an  in- 
flammatory mass  around  the  vagina. 


PALPATION  OF  BLADDER  AND  URETHRA 

BASE  OF  BLADDER. 


43 


Tenderness,  Induration. 

The  base  of  the  bladder  lies  directly  beneath  the  central  part  of  the  anterior 
vaginal  wall  and  is  readily  palpated.  In  cystitis  or  other  painfvd  afifection 
involving  the  base  of  the  bladder,  tenderness  is  found.    When  induration  or 


Fig.  55.     The  bony  arch,  which  bound.s  the  vaginal  opening  above. 

abnormal  hardening  or  thickening  is  found,  ascertain  whether  it  is  a  di.stinct 
mass  with  definite  outlines  (foreign  body  or  tumor  of  the  bladder),  or  a  dif- 
fuse infiltration  (inflammatory,  tubercular,  malignant)  of  the  bladder  wall 
or  of  the  vesico-vaginal  septum. 

URETHRA. 

Tenderness,  Induration,  Discharge. 

The  urethra,  as  it  extends  from  the  bladder  forward  under  the  pubic  arch, 
is  easily  palpated  through  the  anterior  vaginal  wall,  immediately    beneath 


44  THE  PHYSICAL   EXAMINATION 

which  it  lies.  In  inflammation  of  the  urethra  there  is  usually  considerable 
tenderness,  and,  in  many  cases,  decided  induration  or  thickening.  A  thicken- 
ing due  to  a  new  growth  may  be  easily  outlined  in  this  way.  Palpate  the 
urethra  from  within  outward — i.  e.,  from  the  bladder  toward  the  meatus. 
The  palpation  is  more  accurately  and  conveniently  accomplished  in  that  way, 
and  at  the  same  time  any  discharge  in  the  urethra  is  carried  to  the  meatus, 
where  it  is  seen  and  a  specimen  secured  for  microscopic  examination. 

Remember  that  inflammation  may  persist  indefinitely  in  Skene's  glands, 
just  within  the  meatus.  To  secure  secretion  from  the  glands  for  examination 
in  such  cases,  introduce  the  index-finger  within  the  vagina  and  compress  the 
urethra  just  back  of  the  meatus,  and  then  move  the  finger  forward.  In  parous 
women  the  opening  of  each  gland  may  often  be  found  by  rolling  out  the 
urethral  mucosa  slightly  and  examining  closely  for  the  opening  (Fig.  48). 

VULVO-VAGINAL  GLAND. 
Tenderness,  Induration,  Discharge,  Red  Spot. 

The  vulvo-vaginal  gland  (gland  of  Bartholin)  of  each  side  lies  just  lateral 
to  the  remnants  of  the  hymen,  and  opens  by  a  short  duct  in  front  of  and 
a  little  below  the  middle  of  the  lateral  margin  of  the  hymenal  attachment. 
A  convenient  way  to  palpate  the  glands  is  to  catch  the  tissues  lateral  to  the 
gland  opening  (the  opening  may  be  easily  seen  in  the  situation  just  described) 
between  a  finger  in  the  vagina  and  the  thumb  outside  (Fig.  51). 

When  normal,  the  gland  is  scarcely  noticeable  by  ordinary  palpation. 
When  inflamed,  however,  there  is  thickening",  and  the  gland  is  felt  as  a  small 
firm  nodule. 

There  is  tenderness  also,  and,  if  the  gland  is  pressed  upon,  some  discharge 
(pus)  may  appear  from  duet.  Make  a  smear  preparation  of  this  for  staining 
for  gonococci. 

In  a  case  of  abscess  or  cyst  the  nodule  will  be  much  larger.  A  well-marked 
red  spot  or  small  red  area  involving  the  opening  of  the  gland  duct  indicates 
previous  inflammation  of  the  duct,  and  is  presumptive  evidence  of  a  previous 
gonorrhoeal  infection  (as  other  forms  of  inflammation  seldom  invoh^e  the 
gland  or  duct),  and  should  always  lead  to  further  investigation,  to  establish 
the  presence  or  absence  of  this  disease. 

PELVIC  FLOOR. 

Size  of  Vaginal  Opening,  Resistance  to  Backward  Pressure  on  Pelvic  Floor, 

Protrusion  of  Vaginal  Walls,  Scars  or  Distortions, 

Thickness  of  Perineal  Body. 

Is  there  loss  of  support  at  the  pelvic  outlet?  Is  there  so  much  relaxation, 
due  to  imperfect  healing  of  an  open  tear  or  of  a  subcutaneous  tear,  or  due  to 
subinvolution  of  the  pelvic  sling,  that  the  pelvic  organs  arc  not  satisfactorily 
supported?   To  determine  this,  investigate  the  following  points; 


TESTING  THE    PELVIC  FLOOR 


45 


Size  of  Vaginal  Opening.  In  the  adult  virgin  the  opening  in  the  hymen 
Avill  usually  admit  tlie  little  finger  without  much  stretching.  In  a  married 
woman  two  fingers  can  usually  be  introduced  for  examination  without  caus- 
ing pain,  provided  the  care  previously  mentioned  is  exercised. 

If  the  vaginal  opening  will  readily  admit  three  fingers,  it  is  decidedly  en- 
larged and  there  is  considerable  interference  with  the  integrity  of  the  perineal 
body.  The  perineal  body  is  not,  however,  an  iini)()rtant  factor  in  the  real 
supporting  power  of  the  ])elvie  floor;  hence  a  relaxed  vaginal  opening  does 


Testing  the  left  sulcus. 


not  necessarily  mean  a  relaxed  pelvic  sling,  though  it  usually  accompanies 
the  same. 

Resistance  to  Downward  and  Backward  Pressure  on  the  Pelvic  Floor. 
Usually  in  the  woman  who  has  borne  children  there  is  not  the  firm  support 
back  of  the  posterior  vaginal  wall,  and  extending  well  up  toward  the  cervix, 
that  is  found  in  nullipara.  There  is  not,  however,  the  marked  difference  one 
would  naturally  expect  from  the  enormous  stretching  that  necessarily  takes 
place  in  childbirth. 

The  pro-sdsions  of  nature  for  the  restoration  of  the  parts  to  near  their 
former  condition  are  wonderfully  effective  when  not  interfered  with  by  tears 
or  over-stretching  or  subinvolution. 

The  resistance  in  each  sulcus  may  be  tested  with  one  finger,  as  shown  in 


46 


THE  PHYSICAL  EXAMINATION 


Fig.  56,  to  determine  if  there  has  been  a  tear  in  the  levator  ani  in  that  region, 
with  consequent  relaxation. 

A  much  more  satisfactory  method  of  testing  the  integrity  of  the  pelvic 
tloor  is  to  introduce  the  two  examining  fingers  and  turn  them  so  that  their 
palmar  surfaces  are  directed  backward.  Then  press  backward  and  downward 
on  the  pelvic  floor,  at  the  same  time  separating  the  fingers  as  widely  as  pos- 
sible (Fig.  57). 

The  fingers  in  the  vagina  are  separated  as  shown  in  Fig.  58.  This  maneuver 
will  give  a  very  good  idea  of  the  amount  of  support  furnished  by  the  pelvic 
sling  and  of  the  downward  displacement  of  the  pelvic  organs  that  is  per- 
mitted when  the  patient  is  standing.  Another  useful  method  is  to  introduce 
the  two  index  fingers,  side  by  side,  into  the  vagina  and  then  separate  them 
widely  in  a  direction  downward  and  outward  (Fig.  59).    If  the  fingers  can  be 


Fig.  57.  Testing  the  pelvic  floor.  The  vaginal 
fingers  are  separated  widely,  as  explained  in  Fig. 
58,  and  pressed  downward. 


Fig.  58.  Showing  the  relative  position  of  the 
fingers  when  in  the  vagina,  while  testing  the  pelvic 
floor. 


carried  to  the  bony  sides  of  the  arch  with  but  little  muscular  resistance,  the 
front  part  of  the  levator  ani  muscle  and  accompanying  fascia  has  been  torn, 
and  there  is  decided  loss  of  support  in  the  pelvic  floor.  If  now  the  patient 
be  directed  to  bear  down,  the  loss  of  support  l)eeomes  still  more  evident. 

Occasionally,  even  in  case  of  marked  injury  to  the  pelvic  sling,  tlie  support 
will  seem  very  good  during  the  first  part  of  the  examination  because  of  the 
muscular  tension.    • 

The  strong  fascial  layer  of  the  pelvic  sling  probably  constitutes  tlie  prin- 
cipal factor  in  continuous  support,  for  the  muscles  cannot  contract  continu- 
ously. 


TESTING  THE   PF^LVIC   FLOOR 


47 


Now,  the  fascia  may  be  so  torn  and  stretched  that  it  furnishes  litth^  or  no 
continuous  support,  and  yet,  as  long  as  the  muscles  stay  contracted,  there 
seems  to  be  a  fairly  good  pelvic  floor.  Any  error  in  Ihis  respect  may  be 
avoided  by  watching  for  it,  and  securing  entire  rehixation  before  the  exami- 
nation is   finished. 

Protrusion  of  Anterior  or  Posterior  Wall.  To  furtlier  test  the  loss  of  sup- 
port, separate  the  labia  and  instruct  the  patient  to  ])ear  down.  Tlie  resulting 
bulging  of  the  structures  gives  some  idea  of  how  poorly  the  pelvic  floor  sup- 
ports the  organs,  provided  the  patient  really  bears  down  when  she  thinks  she 
does.  The  downward  displacement  of  the  vaginal  Avails  and  pelvic  diaphragm 
may  be  still  further  shown  by  introducing  tlie    two  examining    fingers    and 


Fig.  ."i9.     Testing  the  pelvic  floor  by  tlie  two  index  *ingers,  introduced  togetlier  and  then  separated. 


pressing  backward  and  downward,  at  the  same  time  separating  the  fingers 
widely,  as  mentioned  in  testing  the  strength  of  the  pelvic  floor. 

When  the  patient  is  in  the  upright  posture,  this  downward  displacement 
of  the  vaginal  wall  is  of  course  more  marked,  particularly  in  cases  of  pro- 
lapse of  uterus  and  vaginal  walls.  But  it  is  rarely  necessary  to  examine  a 
patient  in  the  standing  posture,  for  the  diagnosis  as  to  the  character  and 
extent  of  her  trouble  may  usually  be  made  without  it. 

Scars  or  Distortions  of  Vaginal  Wall  or  Perineum.  Sometimes  there  are 
deep  scars  running  up  the  vaginal  wall  at  the  site  of  tear,  indicating  a  severe 


48 


THE  PHYSICAL  EXAMINATION 


injury  of  the  pelvic  sling.     These  scars  may  extend  out  onto  the  perineum 
and  be  seen  in  the  inspection  already  mentioned. 

Thickness  of  Perineal  Body.  The  thickness  of  the  perineum  remaining  may 
readily  be  determined  by  catching  the  perineal  tissue  between  the  finger  in 
the  rectum  and  thumb  in  the  vagina.  A  membraneous  perineum  (torn  inter- 
nally, but  not  much  on  the  skin  surface)  may  be  demonstrated  by  examininp^' 
with  a  finger  in  the  vagina  and  the  thumb  outside  over  the  perineum. 

RECTITI\r. 
Tenderness,  Induration,  Hemorrhoids,  Fistula,  Fissure. 
Above  the  perineum  the  anterior  rectal  wall  is  closely  applied  to  the  pos- 


Fig.  60.     Palpation  of  rectum  through  posterior  vaginal 
wall.     (Ashton — Practice  of  Gynecology.) 


Fig.  61.     Method  of   everting 
inspection. 


the  anal  tissues  for 


terior  vaginal  wall.  Turn  the  examining  fingers  so  that  the  palmar  surfaces 
are  directed  backward,  and  palpate  the  rectum  (Fig.  60).  If  there  is  any  pain- 
ful affection  in  that  portion  of  the  rectum,  there  will  be  decided  tenderness. 
If  an  induration  is  felt,  determine  whether  it  is  a  distinct  mass  with  definite 
outlines  (foreign  body,  fecal  material,  tumor  in  rectum),  or  a  diffuse  infiltra- 
tion (inflammatory,  syphilitic,  tubercular,  malignant).  Very  frequently  firm 
fecal  masses  will  be  felt  through  the  posterior  vaginal  wall.  Sometimes  these 
are  large  enough  to  cause  a  bulging  of  a  part  of  the  wall,  while  in  exceptional 
cases  they  are  so  large  as  to  interfere  decidedly  with  bimanual  examination. 
In  the  lower  part  of  the  rectum  these  masses  cause  no  trouble  in  diagnosis, 
for  in  that  situation  their  character  is  easily  recognized.   In  the  upper,  part  of 


EXAMINATION  OF  THK  RECTUM 


49 


the  rectum,  however,  and  in  llic  siomoid  region  such  a  mass  may  cause  cou- 
I'usion  in  diagnosis,  for  it  may  resemble  a  prolapsed  ovary  or  an  inflammatory 
mass  in  the  cul-de-sac  or  about  the  tube. 

The  distinguisliing  characteristics  of  a  fecal  mass  are  three:  (a)  it  is  not 
particularly  tender,  ()))  it  has  usually  a  putty-like  consistency  and  may  be 
dented,  the  dent  remaining,  and  (c)  it  may  sometimes  be  pushed  along  to  a 
different  position  in  the  bowel.  •  In  a  doubtful  case  the  bowels  should  be 
moved  thorouglily  l)y  a  purgative  and  the  rectum  cleared  with  an  enema,  and 
the  patient  again  examined. 

In  a  patient  with  a  lax  pelvic  floor  the  anal  tissues  may  lie  everted  by  pres- 
sure from  within  the  vagina  by  one  or  two  fingers,  as  indicated  in  Fig.  61 


Fig.  62.     Indicating  the  amount  of  possible  eversion  of  anal  tissues  when  the  pelvic  floor  is  lax.     cniidley- 
Pradice  of  Gynecology.) 


When  the  tissues  are  very  lax,  the  anus  may  ])e  opened  widely  and  the  rectal 
mucosa  exposed  (Fig.  62).  This  turning  out  and  examination  of  the  anal  tissues 
is  advisable  whenever  there  is  pain  on  defecation,  or  bleeding  or  other  evi- 
dence of  trouble  in  this  region.  In  this  way  the  presence  or  absence  of 
hemorrhoids  or  fistula  or  fissure  may  be  determined. 


50  .  THE   PHYSICAL  EXAMINATION 


CERVIX  UTERI. 


Position,  Size,  Shape,  Consistency,  Tenderness,  Mobility,  Attachments,  Direc- 
tion in  Which  it  Points,  Laceration  with  Eversion  of  Lips, 
Size  and  Shape  of  External  Os. 

Tlie  cervix  uteri  is  felt  at  the  upper  end  of  the  Tagina  as  a  firm,  conical 
body,  projecting  through  the  upper  portion  of  the  anterior  wall  (Figs.  1  and 
3).  It  is  distinguished  from  the  surrounding  vaginal  wall  by  its  greater  hard- 
ness. 

Position  of  Cervix.  The  normal  position  of  the  cervix  is  from  three  to  three 
and  one-half  inches  from  the  vaginal  orifice.  The  fingers  are  carried  toward 
the  top  of  the  vagina  until  the  tip  of  the  finger  touches  the  cer^dx.  If  the 
vaginal  orifice  comes  well  up  to  the  upper  end  of  the  third  joint  of  the  finger, 
the  cervix  is  in  normal  position  (1  assume  a  hand  of  average  size,  "^^-ith  index 
finger  about  three  and  three-fourths  inches  long).  If  the  cer-^ix  is  encountered 
by  the  finger  before  it  is  introduced  that  far,  the  cervix  is  too  low.  If  not 
encountered  at  that  point,  it  is  too  high.  The  diagnostic  significance  of  ab- 
normal position  of  the  cervix  is  given  in  chapter  II  (page  231). 

In  cases  where,  after  examination  in  the  dorsal  posture,  it  is  still  uncertain 
as  to  whether  or  not  there  is  serious  descent  of  the  uterus,  the  patient  may 
be  examined  in  the  standing  posture.  The  patient  stands,  with  one  foot  slightly 
elevated,  on  the  round  of  a  chair  or  on  a  small  stool,  while  the  examiner,  sit- 
ting on  a  chair  in  front  of  her,  makes  the  vaginal  examination.  In  this  pos- 
ture a  decided  descent  of  the  uterus,  which  might  disappear  when  the  patient 
lies  down,  is  at  once  appreciable.  Examination  in  this  position  is  employed 
also  to  detect  the  ballottement  of  early  pregnancy  in  doubtful  cases.  Exami- 
nation in  this  posture,  however,  is  rarely  required,  for  in  almost  all  cases  the 
information  necessary  to  a  diagnosis  may  be  obtained  by  the  more  common 
methods  of  gynaecological  investigation. 

Size  and  Shape.  The  size  and  shape  of  the  cervix  varies  much  in  different 
individuals,  and  in  the  same  individual  at  different  periods  of  life.  In  women 
who  have  never  been  pregnant  the  normal  cer^dx  has  the  shape  of  a  rounded 
cone  about  one  inch  wide,  and  projects  into  the  vagina  from  one-half  to  three- 
quarters  of  an  inch.  The  external  os  is  small  and  round,  and  is  at  tlie  flat- 
tened apex  of  the  cone. 

In  certain  abnormal  cases  the  cervix  is  very  long  (an  inch  to  an  inch  and 
a  half)  and  pointed.  This  condition  is  known  as  conical  cervix.  It  is  fre- 
quently accompanied  by  a  very  small  external  os  ("pinhole  os"),  and  is  one 
cause  of  sterility. 

In  women  who  have,  borne  children  the  cervix  is  larger  and  broader,  and 
comparatively  shorter.  The  os  is  a  transverse  slit  and  is  irregular  in  shape, 
and  may  be  large  enough  to  admit  the  finger-tip.  There  are  usually  small 
scars  and  irregular  depressions  from  lacerations  in  labor.  AVhen  the  cervix 
has  been  severely  lacerated,  there  may  be  two  or  three  distinct  lips.    Again, 


VARIOUS  POINTS  CONCERNINn  THE  CRUVIX  IITF.RI  51 

it  may,  on  account  of  chronic  inflammation,  become  enlarged  to  two  or  three 
times  its  normal  size  and  may  be  felt  as  an  irregular  ball  at  the  top  of  the 
vagina. 

Consistency.  The  normal  cervix  is  like  hard  connective  tissue,  almost  as 
liard  as  tendon.  Its  consistency  is  closely  approached  by  that  of  the  end  of 
the  nose  when  firmly  pressed  upon.  During  pregnancy  the  cervix  softens, 
the  softening  beginning  at  the  lower  end  and  gradually  involving  more  and 
more  as  pregnancy  advances.  The  softening  is  so  marked  that  the  softened 
portion  is  sometimes  missed  entirely,  the  cervix  being  apparently  simply 
shortened.  This  is  what  gave  rise  to  the  former  idea  that  the  cervix  became 
gradually  shortened  as  pregnancy  advanced.  The  softened  portion  feels  like 
thick  velvet  or  a  fold  of  vaginal  wall  as  it  slips  back  and  forth  beneath  the 
examining  finger.  It  is  hard  to  describe  satisfactorily,  but  when  once  felt  is 
easily  recognized  afterward.  A  partial  idea  of  it  may  be  secured  by  the  fol- 
loAving  experiment.  Cover  a  finger  M'ith  a  piece  of  heavy  velvet  with  a  very 
thick  nap,  the  nap  side  out.  Then  shut  the  eyes  and  with  the  otiier  hand, 
with  the  fingers  usually  used  in  vaginal  examination,  endeavor  to  make  out 
exactly  the  thickness  of  the  nap  by  passing  the  fingers  over  it  with  varying 
pressure  and  in  different  directions.  First  make  firm  pressure  so  as  to  appre- 
ciate the  fingers  beneath,  then  make  light  pressure  so  as  to  estimate  the  thick- 
ness of  the  nap.  These  same  maneuvers  are  carried  out  in  appreciating  the 
presence  and  extent  of  marked  softening  of  the  cervix. 

This  softened  velvety  condition  of  the  cervix  is  very  characteristic  and 
should  always  arouse  suspicion  of  pregnancy.  Some  softening  of  the  cervix 
is  found  in  certain  cases  of  inflammation  of  the  cervix,  and  also  in  cases 
where  its  circulation  is  interfered  with,  as  when  the  pelvis  is  filled  with  a 
tumor  or  with  a  mass  of  inflammatory  exudate,  or  where  there  is  marked  dis- 
placement of  the  uterus. 

Abnormal  hardening  of  a  portion  of  the  cervix  may  be  due  to  scar  tissue, 
to  cystic  disease,  to  a  fibroid  nodule  or  to  malignant  infiltration. 

Tenderness  of  Cervix.  The  cervix  is  much  less  sensitive  than  the  vaginal 
wall,  and  rarely  becomes  very  sensitive  even  when  diseased.  The  pain  com- 
plained of  when  the  cervix  is  pressed  upon  is  usually  due  to  the  pulling  upon 
inflamed  periuterine  structures,  by  the  resulting  movement  of  the  uterus. 

Mobility  of  Cervix.  Normally  the  cervix  is  freely  and  painlessly  movable 
for  a  short  distance  in  all  directions.  Its  range  of  mobility  may  be  dimin- 
ished by  scar  tissue  or  by  malignant  infiltration  in  the  upper  part  of  the 
vagina,  or  by  an  inflammatory  exudate  in  the  pelvis,  or  by  a  uterine  tumor 
or  by  any  pelvic  tumor  that  fixes  the  uterus.  Its  range  of  mo])i]ity  may  be 
increased  by  laceration  or  overstretching  of  the  supports,  posteriorly  or  an- 
teriorly or  laterally,  a  frequent  accompaniment  of  pelvic  floor  injuries. 

Attachment  of  Cervix.  Is  the  cervix  attached  or  fixed  to  the  pelvic  wall  at 
some  point  ?   If  so,  where  and  by  what  ? 

Direction  of  Cervix.  Does  the  cer\ncal  canal — i.  e.,  the  axis  of  the  cervix — 
point  across  the  vagina,  about  toward  the  coccyx,  as  it  should  (Figs.  1  and 


52  THE  PHYSICAL  EXAMINATION 

3)  ?  When  you  find  the  cervix  pointing  along  the  vagina  toward  you,  do  not 
jump  at  the  conclusion  that  there  must  be  a  backward  displacement  of  the 
uterus.  It  may  be  that  other  rather  common  condition — anteflexion  of  the 
cervix. 

Laceration  of  Cervix,  Eversion  of  Lips.  The  presence  or  absence  of  this 
condition  is  determined  when  ascertaining  the  size  and  shape  of  the  cervix. 
For  the  various  conditions  thus  produced  see  chapter  II  (pages  292  to  294). 

Size  and  Shape  of  External  Os.  These  items  are  determined  by  palpation  of 
the  OS  when  ascertaining  the  general  size  and  shape  of  the  cervix.  The 
various  conditions  of  the  external  os  are  shown  in  chapters  II  and  VI  (pages 
291,  237). 

PERICERVICAL  TISSUES. 

Tenderness,  Induration. 

The  tissues  about  the  cervix,  immediately  beneath  the  vaginal  wall,  may  be 
palpated,  and  tenderness  or  induration  noted.  If  induration  is  present,  note 
whether  it  is  a  distinct  well-defined  mass  or  diffuse  infiltration  and  thicken- 
ing of  the  tissues. 


VAGINO-ABDOMINAL  EXAMINATION    (BIMANUAL). 

The  vagino-abdominal  examination  is,  as  its  name  implies,  an  examination 
from  the  vagina  and  the  abdomen  at  the  same  time.   The  pelvic  structures  are 
caught  between  the  fingers  in- the  vagina  and  the  fingers  over  the  abdomen, 
and  carefully  examined  by  indirect  touch  (Figs.  63,  64).     By  it  the  body  of 
the  uterus  is  located  and  outlined.    The  region  to  each  side  of  the  uterus  is. 
palpated  and  also  the  space  back  of  the  uterus.    It  is  determined  if  there  is 
any  abnormal  mass  in  the  pelvis  or  if  there  is  any  area  of  marked  tenderness. 
To  the  beginner  in  gynecological  work  this  important  bimanual  examina- 
tion is  often  unsatisfactory.    He  has  heard  a  great   deal   about  tubal   and 
ovarian  disease,  and  he  expects  to  feel  the  tube  and  ovary  at  once.   He  exam- 
ines a  patient,  or  several  patients,  and  can  feel  neither  tube  nor  ovary  if  they 
are  normal.    Then  he  is  discouraged,  and  thinks  that  he  has  learned  nothing 
from  the  examination.   And  probably  he  has  not  learned  much,  for  the  simple 
reason  th,at  he  was  feeling  for  something  that  he  could  not  feel,  and  did  not 
know  the  significance  of  what  he  did  feel.    Close  attention  to  the  details  of 
the  examination  will  prevent  this  unprofitable  experience. 

The  information  concerning  the  Bimanual  Examination  may  ])e  divided  as 

follows  : 

Palpation  of  Uterus — Position,  Size,  Shape,  Consistency,  Tenderness, 

Mobility,  Attachments. 
Palpation  of  Tubo-ovarian  Region — Tenderness,  Mass  or  Induration. 
Palpation  of  other  Regions — Tenderness,  Mass  or  Induration.    ■ 


PALPATION  OF  THE  BODY  OP'  THE  UTERUS 


53 


General  Observations — Impoi-tance  ol'  tlu'  Educated  Touch,  Traiu 
One  Hand,  I'se  Two  Fingers,  Examine  Deeply  in  I'elvis,  May 
Draw  Down  Uterus,  Preferable  Position  Tor  Examiner,  C'ondi- 
tions  in  Different  Patients,  Get  Intestines  out  of  the  Way,  Dimin- 
ish Tenderness. 


PALPATION  OF  BODY  OF  UTERUS. 
Position,   Size,   Shape,   Consistency,   Tenderness,   Mobility,   Attachments. 

Locating  the  Corpus  Uteri. 
Steps.    Tile  locating  of  the  corpus  uteri  will  l)e  much  racilitated  Ity  pi-oceed- 
iug  as  follows : 


Fig.  63.  Bimanual  Examination,  showing  also  the 
disposition  of  outside  fingers  and  left  thumb.  (Kelly 
— Operative  Gynecology.) 


Fig.  64.  Showing  the  other  disposition  of  third 
and  fourth  fingers  along  the  gluteal  crease.  This 
allows  deeper  penetration  of  the  examining  fingers  in 
certain  exceptional  cases,  particularly  in  very  stout 
patients.     (Kelly — Operative  Gynecology.) 


1.  With  two  fingers  in  the  vagina,  locate  the  cervix  and  tlien  push  the 
cervix  backward  and  upward. 

2.  Then,  with  the  fingers  of  the  abdominal  hand  depressing  the  abdominal 
wall  into  the  depth  of  the  pelvis  back  of  the  uterus,  bring  the  fundus  uteri 
w^ell  forw^ard. 

3.  Then,  with  the  pressure  still  maintained  in  the  direction  indicated,  slip 
the  vaginal  fingers  in  front  of  the  cervix  (Fig.  65).  The  body  of  the  uterus  is 
thus  caught  firmly  between  the  fingers  below  and  above,  and  may  be  clearly 
felt  and  outlined. 


54 


THE  PHYSICAL  EXAMINATION 


Two  Common  Errors.    The  following  errors  are  made  so  often  by  students 

and  practitioners  that  I  think  it  advisable  to  call  particular  attention  to  them. 

Error  1.  Depression  of  the    Abdominal  Wall  too  Close  to  the  Pubes.   If  the 

uterus  happens  to  be  far  forward,  this  causes  no  trouble,  but  if  the  uterus  is 
very  high,  as  it  frequently  is  from  a  few  hours'  urine  in  the  bladder  or  other 
normal  or  abnormal  cause,  the  depression  of  the  wall  close  to  the  pubes  tends 
to  push  the  uterus  backward  (Figs.  66,  67).  Conseciuenth^  it  is  not  felt  be- 
tween the  examining  fingers,  though  there  is  no  real  displacement,  or  was  none 
before  this  examination  was  begun. 

To  avoid  this  error,  depress  the  abdominal  wall  near  the  promontory  of  the 


Fig.  65.     Showing  the  third  step  in  the  palpation  of 
the  uterus.     (Montgomery — Practical  Gynecology.) 


Fig.  66.  Depression  of  the  abdominal  wall  too 
close  to  pubes.  Sectional  view,  (.\shton — Practice 
of  Gynecology.) 


sacrum,  about  midway  between  the  pubes  and  the  umbilicus  (Fig.  68).  In 
particularly  difficult  cases  it  is  well  to  start  very  high  and  bring  the  fingers 
down  upon  the  sacral  promontory,  and  then  allow  them  to  slip  over  the  promon- 
tory into  the  posterior  part  of  the  pelvis.  They  are  then  brought  forward 
until  the  body  of  the  uterus  is  felt  or  until  the  vaginal  and  alidominal  fingers 
are  so  closely  approximated  that  the  absence  of  the  uterus  from  that  part  of 
the  pelvis  is  demonstrated. 

Error  2.  Frequent  Shifting  of  the  Position  of  the  Abdominal  Fingers.  Sonu^ 
students  gouge  about  in  the  lower  abdomen  in  various  directions  in  an  effort 
to  feel  the  fundus  uteri  with  the  abdominal  fingers.  This  is  likely  to  make 
the  examination  a  failure  in  a  normal  ease  and  it  is  almost  certain  to  (;lo  so 


LOCATING   THK   COKI'US   UTP:K1 


55 


iu  u  difficult  ease.  Reiiienibci-  llial  Icnsiou  of  ilic  alxlominal  wall  iuterleres 
with  the  examination  and  may  defeat  it  entirely.  KeincinlxM-  also  that  the  ten- 
sion is  increased  l)y  fre(iuent  luovements  of  the  alidoiiiinal  fin^'ers,  sueh  as 
l)laeino:  tlieiii  in  one  position  after  another  in  rajjid  suc«-cs.sion,  and  particn- 
lai-ly  l)y  endeavoring  to  gouge  in  rai)idly  and  forcibly  in  vai-ious  parts  of  the 
pelvis  in  an  endeavor  to  overcome  the  i-esistauce  of  the  wall.  Keep  in  mind 
that  most  of  the  effective  palpation  is  done  with  the  vaginal  fingers,  the 
principal  function  of  the  abdominal  fino-crs  being  to  ])ring  the  body  of  the 
uterus  Avithin  reach  of  the  vaginal  fingers  and  then  hold  it  there  while  palpa- 


< 

> 

: 

"  \  -                             -:       - 

*! 

Fig.  67.     Depres.sion  of  abdominal  wall  too  close  to 
the  pubes.     Outside  view. 


Fig.  G8.       Depression   of  abdominal    wall    at    tlie 
proper  height. 


tion  is  being  carried  out.    Get  clearly  in  ndnd  just  exactly  what  movements 
are  necessary  to  best  palpate  the  uterus. 

In  order  to  avoid  this  error  just  mentioned,  place  the  abdominal  fingers  so 
that  the  depression  of  the  wall  wall  be  into  the  back  part  of  the  pelvis,  and 
then  carry  the  fingers  by  steady  and  continuous  pressure  toward  the  desired 
region.  When  you  have  advanced  the  fingers  as  far  as  possible,  hold  them 
there  steadily  and  direct  the  patient  to  take  a  deep  breath  and  then  to  let  the 
breath  all  out.  As  expiration  takes  place,  the  fingers  may  be  carried  deeper 
into  the  pelvi.s — not  by  any  sudden  forcing  movement,  but  by  strong  steady 
pressure  that  does  not  excite  muscular  contraction  and  resistance.  If  still 
the  fingers  are  not  deep  enough  in  the  pelvis,  the  same  movements  may  be  re- 


56  THE  PHYSICAL  EXAMINATION 

peated  several  times.    Because  the  uterus  is  not  felt  at  once,  do  not  cease  the 
pressure  there  and  begin  to  depress  the  ^vall  at  some  other  place.     Start  the 


Fig.  69.      Explaiiiing   one    condition    in  Fig.    70.     Search  is  then  made  in  the  pos- 

which  the  uterus  is  not  found  in  the  front  tsrior  part  of  the   pehis,  and  the  uterus  is 

part  of  the  pehis.       (Ashton — Practice  of  found    in  retroversion.     (Ashton — Practice 

Gynecology.)                                   '  of  Gynecology.) 


Fig.  71.     Indicating  the  examination  findings  when  the  uterus  is  in  retroflexion.     Notice  the  marked  angle 
which  is  palpable  posteriorly  at  the  junction  of  the  cervix  and  corpus  uteri.    (.Vshton — Practice  of  Gynecology.) 

fingers  in  the  right  direction  at  first  and  then  keep  them  going  in  that  direc- 
tion steadily,  firiidy,  persistently,  -without  relaxing  the  pressure,  until  the 
depth  of  the  pelvis  is  reached  and  the  uterus  felt. 


FACTS  TO  DETERMINE  ABOUT  CORPUS  UTERI  57 

In  tlic  subsequent  steps  ol'  the  palpation  ul'  llie  uterus  llic  slight  move- 
ment ol!  the  abdominal  lingers  that  is  necessary  to  bring  them  in  position  for 
good  counter-pressure  at  the  various  parts  of  the  uterus  may  usually  be  made 
Avithout  relaxing  the  pressure,  as  the  skin  is  loose  enough  to  ])e  slipped  about 
over  the  underlying  structures. 

If  the  body  of  the  uterus  is  not  found  in  front  of  the  cervix  (Fig.  69),  then 
search  behind  the  cervix  (Figs.  70,  71)  and  then  to  each  side  of  it.  If  the 
patient  has  no  mass  obstructing  the  pelvis  and  no  extreme;  tension  of  the 
abdominal  wall,  the  body  of  the  uterus  should  be  distinctly  made  out. 

Facts  to  Determine. 

AVhen  the  l)0(ly  of  the  uterus  has  been  located,  then  tix  in  mind  the  following 
facts  concerning  it  : 

1.  Position  of  the  Corpus  Uteri.  Is  it  in  anterior  position,  as  it  should  Ix', 
or  is  it  disi)laeetl  l)acl\\vard  or  drawn  to  one  side? 

2.  Size  of  Corpus  Uteri.  Is  it  apparently  normal  in  size  (about  three  inches 
long),  or  is  it  as  large  as  the  fist,  or  as  large  as  a  child's  head?  Figs.  72  and 
7o  indicate  the  method  of  palpating  the  margin  of  the  uterus  and  also  the 
method  of  determining  its  width  by  separation  of  the  vaginal  fingers. 

3.  Shape  of  the  Corpus  Uteri.  Is  it  approximately  pear-shaped  and  of  regu- 
lar contour,  or  is  it  distorted  by  fibroids  or  other  tumors? 

4.  Consistency  of  Corpus  Uteri.  Is  it  apparently  a  firm,  solid  body  or  does 
it  contain  fluid,  or  are  there  hard  nodules  in  it,  or  is  there  marked  softening? 

5.  Tenderness  of  Corpus  Uteri.  Does  pressure  on  the  uterus  cause  pain  or 
does  the  attempt  to  move  it  cause  pain? 

6.  Mobility  of  Corpus  Uteri.  Can  the  uterus  be  moved  freely  up  and  down, 
to  right  and  left,  forward  and  back-ward,  or  is  it  fixed  more  or  less  firmly  by 
an  inflammatory  exudate  or  by  a  tumor? 

7.  Attachment  of  Corpus  Uteri.  Does  the  uterus  seem  to  be  attached  or 
fixed  to  the  pelvic  wall  at  some  point  ?    If  so,  where  and  by  what  ? 

When  it  is  impossible  to  reach  the  various  parts  of  the  uterus  sufficiently 
to  obtain  the  necessary  information,  the  cervix  may  be  caught  with  a  tenacu- 
lum forceps  and  the  uterus  pulled  somewhat  downward  (Fig.  74).  Care 
should  be  taken,  however,  not  to  pull  the  uterus  down  very  far,  for  reasons 
explained  later  (page  71). 


PALPATION  OF  LATERAL  REGIONS  OF  PELVIS. 

Tubes  and  Ovaries,  Mass,  Induration,  Tenderness. 

In  this  region,  on  each  side,  lies  the  large  area  of  connective  tissue,  beside 
the  cervix  and  lower  part  of  the  corpus  uteri.  Here  induration  from  inflam- 
mation or  other  cause  is  felt  at  once,  low  about  the  cervix,  just  under  the 


58 


THE  PHYSICAL  EXAMINATION 


vaginal  wall.  Higher,  beside  the  uterus,  lie  the  Fallopian  tube  and  the  ovary. 
They  are  near  the  upper  part  of  the  broad  ligament  and  so  close  together  that 
ordinarily  it  is  impossible  to  say,  simply  from  the  position  of  a  mass  there, 
whether  it  springs  from  the  tube  or  from  the  ovary.  Hence  the  region  is 
spoken  of  as  the  "tubo-ovarian"  region,  as  both  organs  lie  there.  The  tubo- 
ovarian  region  lies  high,  and  to  palpate  it  satisfactorily  requires  special  care. 

Steps  in  Palpation  of  the  Lateral  Regions. 

In  palpating  the  tubo-ovarian  region  of  the  left  side,  proceed  as  follows : 


'''^•^.rr 


"^ 


Fig.  72.  Palpating  the  margin 
of  the  uterus,  to  determine  enlarge- 
ment or  irregularity.  (Edgar — 
Practice  of  Obstetrics.) 


Fig.  73.  Estimating  the  width 
of  the  uterus  by  separating  the 
vaginal  fingers  so  that  one  goes  to 
each  side  of  the  uterus.  (Edgar — 
Practice  of  Obstetrics.) 


1.  Place  the  tips  of  the  vaginal  fingers  to  the  left  side  of  the  cervix,  and 
then  push  them  backward  and  outward  and  upward  as  far  as  possible. 

In  order  to  carry  the  finger-tips  sufficiently  far  into  the  posterior  lateral 
area  of  the  pelvis,  it  is  necessary  to  push  the  perineum  for  some  distance  into 
the  pelvis.  This  is  best  accohiplished  usually  by  utilizing  the  force  of  the 
body  muscles,  transmitted  to  the  elbow  either  through  the  knee  (Figs.  75, 
76),  with  the  foot  on  a  small  stool,  or  through  the  iliac  crest  (Fig.  77).  Tliis 
leaves  the  arm  muscles  free  for  tlie  deep  delicate  manipulation  necessary  to 
accurate  palpation  of  the  pelvic  contents. 


PALPATION  OF  TUBO-OVARIAN  REGIONS 


59 


2.  With  the  al)domiual  tiugers  locate  the  anterior  superior  spiuc  of  tlio 
ilium  ou  the  left  side  aud  Iheu  bring  tlie  lingers  diredly  inward  (not  down- 
ward toward  the  pubes,  but  directly  inward  or  slightly  upward)  toward  the 
median  line  for  about  two  inches  (Fig.  78). 

3.  Then,  at  that  point,  depress  the  abdominal  wall  into  the  posterior  ])art  of 
the  side  of  the  pelvis  (Figs.  79,  80)  until  the  tips  of  tlie  abdominal  lingers 
come  close  to  the  tips  of  the  vaginal  fingers.  This  brings  the  lingers  near  to 
each  other  back  of,  or  at  least  in  the  region  of,  the  tube  and  ovary  (Fig.  81). 

-  4.  If  tiie  adnexa  are  not  felt  in  the  back  part  of  the 

pelvis,  then  bring  the  fingers  of  the  two  hands,  held 
in  the  same  relation  to  each  other,  slowly  downward 
toward  the  pubes  (Fig.  82),     In  this  w^ay  the  tube 
and  the  ovary  are  made  to  pass  between  the  examin- 
ing finger-tips  and  may  be  felt  if  decidedly  enlarged. 
The    fingers    are    then    carried    on    downward    and 
toward   the    median   line   in 
order   to    palpate   the    front 
part  of  the  pelvis. 

By  proceeding  gently,  so 
as  not  to  excite  contraction 
of  the  abdominal  muscles, 
and  at  the  same  time  steadily 
pressing  tlie  two  sets  of  fin- 
gers toward  each  other,  a 
little  with  each  expiration, 
the  finger-tips  may  be 
brought  almost  together  in 
the  various  parts  of  the 
pelvis. 

In  these  manipulations  the 
palpation    proper    is    made 
principally  with  the  vaginal  fingers,  the  abdominal  fingers  serving  simply  to 
push  the  structures  down  within  reach  of  tlie  fingers  below. 

A  common  error  is  to  bring  the  tips  of  the  examining  fingers  together  too 
close  to  the  pubes;  hence  the  palpation  is  of  the  tissue  in  front  of  the  tu])e  and 
ovary,  even  if  they  are  in  normal  position.  It  must  be  kept  in  mind  also  tliat 
the  tube  and  ovary  are  likely  to  be  displaced,  especially  if  diseased,  and  the 
displacement  is  nearly  always  backward ;  hence  the  importance  of  getting 
far  back  in  the  side  of  the  pelvis  when  endeavoring  to  accurately  palpate 
these  structures. 

In  order  to  avoid  this  error,  be  certain  that  the  point  of  depression  of  the 
abdominal  wall  is  well  above  the  tubo-ovarian  region,  so  that  when  depressed 
into  the  pelvis  it  wnll  lie  back  of  the  tube  and  ovary. 

In  palpating  the  right  side  of  the  pelvis  follow  the  same  directions,  substi- 
tuting ''right"  for  "left"  (Fig.  83). 


Fig.  74.  Dra'.nngthe  uterus  down  with  a  tenaculum-forceps  to 
bring  it  within  reach  of  the  examining  fingers.  (Dudley — Practice 
of  Gynecology.) 


60 


THE  PHYSICAL  EXAMINATION 


Facts  to  Determine. 

In  the  exploration  in  the  tubo-ovarian  region  take  particular  care  to  search 
for: 

Tube  and  Ovary — usually  not  felt  if  normal ; 
Abnormal  Mass — enlarged  tube  or  ovary,  exudate,  tumor; 
Induration — Inflammatory   infiltration   or    exudate,    adhesions,    scar- 
tissue  ; 
Tender  Area — normal  sensitiveness  of  ovaries,  inflammation,  hyper- 
esthesia, tenderness  from  other  cause. 


Fig.  75.     Invagination  of  tlie  perineum  and  pelvic  floor,  the  force  being  transmitted  through  the  knee. 


Tube  and  Ovary.  In  many  eases  the  normal  lube  and  ovary  cannot  ])e  dis- 
tinctly felt,  even  by  the  experienced  examiner,  and  the  inexperienced  will  find 
it  difficult  even  in  comparatively  easy  cases.  When  the  tube  or  ovary  is  de- 
cidedly enlarged,  it  can  be  felt  to  slip  between  the  examining  fingers  as  a 
distinct  thickening  or  as  a  small  rounded  innss. 

After  locating  the  adnexa,  as  above  desci-il)ed,  it  is  sometimes  advantageous 
to  try  to  trace  the  tube  out  from  the  uterus.   The  fundus  uteri  is  located,  the 


FACTS  TO  DETERMINE  IN  LATERAL  PALPATION 


61 


examining  fingers  (vaginal  and  aluloiuiual  mailing  united  euunler-pressure) 
pass  to  tlie  upper  outer  angle,  ajid  tlu'ii  feel  for  the  tube  as  it  leaves  the  uterus 
and  runs  along  the  top  of  the  broad  ligament.  The  best  place  to  locate  it 
usually,  when  not  abnormally  indurated,  is  just  beyond  the  angle  of  the 
uterus.  It  is  a  much  firmer  cord  here  than  farther  out,  where  the  cavity  be 
comes  large  and  the  tube  soft. 

The  normal  Fallopian  lube  may  be  felt  in  a  suita])le  ease  (thin  patient  with 


Fig.  70.     T'se  of  this  maneuver  forinvatrinating  the  ])elvic  floor  in  tlie  lieep  biniainiul  pulpatii 


relaxed  abdominal  wall  and  i-elaxed  pelvic  floor),  in  the  po.sitiou  indicated, 
as  a  small  soft  cord  about  the  size  of  a  slate-pencil.  It  presents  very  much  tlie 
consistency  of  a  piece  of  rubber  tubing.  It  may,  in  a  suitable  case,  be  traced 
outward  and  is  then  lost  in  a  region  of  the  ampulla,  where  the  tube  becomes 
very  soft  and  the  ovary  comes  into  prominence  as  a  soft  rounded  movable 
body,  a  trifle  larger  than  the  end  of  the  thumb  and  sensitive  to  pressure. 
When  the  tube  is  inflamed  it  becomes  harder  and  larger,  and  is  more  easily 
felt.  It  then  feels  very  much  like  a  rather  firm  piece  of  rubber  tubing  of  about 
the  size  of  a  lead-pencil  or  larger,  extending  outward  from  the  angle  of  the 
uterus,   with   irregular   curves   and  bendings   and   enlargements.    From   thi.s 


62 


THE   PHYSICAL   EXAMINATION 


Fig.  77.     Transmitting  the  force  to  the  elbow  through  the  iliac  crest  in  dsep  bimanual  palpation. 


I'if,'.  7.S.  Palpation  of  the  left  lateral  rcKion.  Plat-- 
ing  tlie  lingers  of  the  abdominal  hand.  They  sliould  be 
on  a  level  with,  or  a  httle  above,  the  anterior  .superior 
spino  fin(nfated  by  tlie  cross.) 


I'ig.  79.    Palpation  of  tlie  left  lateral  region. 
ing  the  abdominal  wall  deeply  into  the  pelvis. 


Depress- 


OTHER  REGIONS  IN  THE  PELVIS 


63 


size  it  may  enlarge  to  a  mass  tliat  fills  all  that  side  of  the  pelvis.  Usually, 
however,  when  the  inflammation  is  at  all  severe,  adhesions  or  plastic  exudate 
surround  the  tube  and  ovary,  binding  them  and  the  surrounding  structures 
together  in  one  mass  and  making  their  separate  differentiation  impossil)lc. 

If  on  examination  the  pelvic  tissues  are  all  soft  and  yielding,  and  no  i)artieu- 
lar  pain  is  caused  by  the  palpation,  you  may  be  certain  that  tlie  tul)es  and 
ovaries  are  not  seriously  diseased,  though  you  may  not  have  felt  them. 

Mass  in  Lateral  Part  of  Pelvis.  The  pelvic  tissues,  with  the  exception  of  the 
uterus,  are  soft  and  yielding,  and  any  firm  body  may  be  felt  tlirough  them, 
either  a  tumor  or  an  inflammatory  exudate  or  a  firm  blood-clot.   Fluid  blood  or 


Fig.  80 
palpation 


A  view  from  anotiier  direction,  showing  tlie  marked  depression  of  the  abdominal  wall  in  deep  pelvic 


serous  exudate  cannot  be  felt  unless  it  is  incapsulated.  If  a  mass  is  found  to 
either  side  of  the  uterus,  determine  concerning  this  mass  the  same  facts  that 
you  did  concerning  the  uterus — namely,  its  position,  size,  shape,  consistency, 
tenderness,  mobility  and  attachments.  Determine  particularly  whether  or 
not  it  is  attached  to  the  uterus,  and,  if  so,  whether  by  a  broad  attachment  or  by 
a  narrow  one. 

Induration  in  the  Lateral  Part  of  Pelvis.    In  some  cases  where  there  is  no  ■ 
distinct  mass  felt,  there  is  a  very  definite  hardening  of  tissues  at  some  point. 
Instead  of  the  tissues  being  soft  and  pliable,  and  easily  pushed  before  the  ex- 
amining finger,  as  they  are  normally,  there  is  a  stiffness  and  fixation  and 


64  THE  PHYSICAL  EXAMINATION 

resistance,  as  though  there  were  infiltration  and  thielvening,  and  the  struc- 
tures beyond  cannot  be  satisfactorily  palpated.  This  resistance  and  fixation  of 
tissue  without  a  well-defined  mass  is  designated  by  the  term  "induration." 
It  may  be  due  to  infiltration  (inflammatory,  tubercular,  malignant)  of  the 
tissues,  to  inflammatory  exudate  on  surfaces,  to  adhesions,  to  scar-tissue  or  to 
a  tumor  not  yet  developed  far  enough  to  form  a  distinct  mass. 

Tender  Area  in  Lateral  Part  of  Pelvis.  The  ovaries  are  usually  rather  sensi- 
tive on  bimanual  palpation,  and  allowance  must  be  made  for  this  normal 
sensitiveness  when  estimating  the  diagnostic  significance  of  tenderness  in  this 
region. 

Tenderness  on  palpation  may  accompany  almost  any  pathological  condition 
in  the  pelvis,  but  it  is  especially  marked  in  inflammatory  trouble,  in  peri- 
toneal irritation  from  blood  in  the  peritoneal  cavity  and  in  neuralgic  affec- 
tions of  the  pelvis. 

PALPATION  OF  OTHER  REGIONS. 
In  the  same  way  as  already  described,  careful  exploration  is  made  of : 

Posterior  Part  of  Pelvic  Cavity — tenderness,  induration,  mass; 

Anterior  Part  of  Pelvic  Cavity — tenderness,  induration,  mass ; 

Ureteral  Regions — tenderness,  induration,  mass ; 

Pelvic  Nerve  Trunks — tenderness; 

Lower  Abdomen — tenderness,  tension,  induration,  mass. 

If  a  mass  is  found,  determine  as  accurately  as  possible  its  position,  size, 
shape,  consistency,  tenderness,  mobility  and  attachments. 

The  method  of  determining  whether  a  mass  is  attached  to  the  uterus,  and, 
if  so,  how  intimately,  is  shown  in  Figs.  84  and  85,  where  the  sulcus  between 
the  uterus  and  the  mass  is  being  palpated  to  determine  its  depth.  In  the  case 
of  a  tumor  with  a  long  pedicle  it  is  well  to  have  an  assistant  hold  the  tumor 
up  in  the  abdomen  out  of  the  way,  while  the  examiner,  by  bimanual  palpation, 
feels  whether  or  not  there  is  any  connection  with  the  uterus  or  appendages. 
Also,  the  uterus  may  be  caught  with  a  tenaculum  forceps  and  pulled  down- 
ward (Fig.  103),  assisting  still  further  in  palpation.  Another  point  is  that  in 
the  case  of  a  broad  attachment  to  the  uterus  the  mass  and  uterus  move  as  one 
body,  whereas  with  a  long  attachment  the  two  may  be  moved  separately. 

In  palpating  the  interior  part  of  the  pelvis,  if  the  body  of  the  uterus 
is  not  felt  in  front  and  still  the  vaginal  and  abdominal  fingers  cannot  be 
brought  well  together,  have  the  patient  pass  the  urine,  and  then  examine 
again.  If  the  patient  cannot  urinate,  or  does  not  seem  to  ein])ty  the  blad- 
der well,  she  may  be  catlieterized.  A  spontaneous  urination  in  the  up- 
right posture  empties  the  bladder  better,  and  is  safer  tlian  eatlieterization, 
which  may  be  followed  by  cystitis.  A.  partly  filled  bladder  is  not  felt 
as  a  distinct  mass,  and  yet  there  may  be  half  a  pint  or  more  of  urine — 
enough    to  make    the  palpation  very    unsatisfactory.      Tlu>    peculiar    thing 


DIFFICULTY  FROM  A  FULL  BLADDER 


65 


about  this  condition  is  that  here  is  nothing  to  indicate  it,  except  the  difficulty  in 
locating  the  body  of  the  uterus  in  deep  palpation.  No  mass  is  felt  and  the  tis- 
sues are  all  soft  and  yield- 
ing and  there  is  no  parti- 
cular pain.  The  fingers 
seem  to  sink  into  the  pelvic 
tissues  well,  but  for  some 
unaccountable  reason  the 
uterus  is  difficult  to  feel.  It 
seems  too  far  back  in  the 
pelvis  and  yet  when  you  try 
to  bring  the  fingers  together 
in  front  of  it,  they  do  not 
come  together  well.  When 
such  a  condition  is  encount- 
ered in  an  apparently  nor- 
mal abdomen  (no  marked 
obesity  or  muscular  tension) 
it  is  probably  due  to  a  collec- 
tion of  urine  in  the  bladder 
or  to  intestinal  coils  in  the 
pelvis.  If  it  does  not  dis- 
appear after  the  bladder  is 


Fig.  81.     The    ovary     caught      between 
(Ashton  —  Practice  of  Gynecology.) 


the     examining      fingers. 


Fig.  82.  The  abdominal  fingers  moving  downward. 


evacuated,  then  elevate  the 
patient's  hips,  to  get  the 
tympanitic  intestinal  coils 
out  of  the  pelvis.  The 
bladder  and  other  tissues  in 
front  of  the  uterus  should 
be  palpated  (Fig.  66)  to 
determine  if  there  is  any 
mass  or  any  marked  tender- 
ness. 

The  region  of  the  ureter  on 
either  side  is  an  interesting 
area  which  is  usualh'  over- 
looked in  pelvic  palpation. 
The  ureter  extends  on  each 
side  from  the  base  of  the 
bladder  backward,  outward 
and  upward,  about  half  an 
inch  from  the  cervix  uteri. 
Ordinarily  it  is  not  felt.  In 
a  suitable  case,  however,  it 
may  be  felt  as  a  rather  in- 
definite cord  or  line  of  ten- 


66 


THE  PHYSICAL  EXAMINATION 


sicn,  extending  from  the  base  of  the  bladder  in  the  direction  indicated.  Fig.  86  in 
dicates  the  method  of  palpating  this  region.  If  inflamed,  the  ureter  is  tender  on 
pressure.  If  infiltrated  and  thickened,  it  is  easily  felt.  If  a  stone  is  lodged  in  the 
lower  portion  of  the  ureter,  it  may  be  felt.  In  this  way  I  was  able  to  determine  de- 
finitely that  a  stone  was  lodged  in  the  left  ureter,  a  short  distance  from  the  bladder, 
in  the  case  of  a  pregnant  woman  with  such  sudden  severe  pain  and  threatening 
symptoms  that  it  was  at  first  feared  that  the  trouble  was  rupture  of  an  extrauterine 
pregnancy.     The  patient  eventually  recovered  and  carried  the  child  to  term. 

If  much  inflammation  has  taken 
place  about  a  stone  or  an  infected 
portion  of  the  ureter,  there  may  be 
considerable  peri-ureteral  infiltra- 
tion that  in  a  measure  obscures  the 
ureter,  and  gives  the  signs  simply  of 
a  cellulitis  at  that  side  of  the  uterus 
and  extending  toward  the  bladder. 
A  cellulitis  associated  with  per- 
sistent bladder  symptoms  should  be 
carefully  investigated,  with  the  idea 
that  it  may  come  from  the  ureter. 
Determine  if  the  induration  runs 
into  the  region  of  the  ureter  and  if 
there  is  tenderness  farther  up  along 
the  ureter  or  in  the  kidney,  or  if  the 
urine  gives  evidence  of  disease  in  the 
urinary  tract.  In  a  considerable 
proportion  of  the  cases  presenting 
persistent  bladder  irritability  and 
classed  as  chronic  cystitis,  the  trouble 
is  really  located  in  the  ureter.  In- 
flammation or  tuberculosis  of  the 
loAver  part  of  the  ureter,  gives  symp- 
toms very  closely  resembhng  chronic 
cystitis. 
In  cases  where  pelvic  neuralgia  or  neuritis  is  suspected,  palpate  the  pelvic  nerve 
trunks  (Figs.  87  and  88).  Sometimes  the  pelvic  tenderness,  which  at  first  seems 
widespread,  may  be  localized  in  its  greatest  intensity  along  the  nerve  trunks  of  one 
or  both  sides.     These  may  be  reached  by  deep  palpation  per  vaginam  or  per  rectum. 


Fig.  83.     Palpating  right  tubo-ovarian  region. 


GENERAL  OBSERVATIONS  ON  BIMANUAL  EXAMINATION. 

It  may  seem  hardly  worth  while  to  take  the  trouble  to  make  out  all  these  little 
points  in  regard  to  the  uterus  or  a  mass  beside  the  uterus,  but  it  is  worth  while,  and 
the  farther  one  advances  in  diagnosis  the  more  he  appreciates  this  fact.  The  abil- 
ity to  make  a  correct  diagnosis  in  deep  seated  pelvic  disease  depends  largely  on  the 
ability  to  answer  the  above  questions  correctly,  and  until  one  can  determine  facts 


EDUCATE  THE  TOUCH 


07 


as  above  indicated,  in  regard  to  the  uterus  or  other  pelvic  mass,  his  diagnosis  is 
simply  a  guess  and  not  a  diagnosis  at  all. 


Importance  of  the  Educated  Touch. 

I  want  to  emphasize  the  importance  of  training  the  hands— of  acquiring  the"tac- 
tus  eruditis."  The  following  quotation  from  an  article  of  mine  on  the  subject 
brings  out  this  point.  "The  multiplication  of  instruments  for  diagnostic  purposes 
has,  to  some  extent,  obscured  the  importance  of  the  educated  touch.  The  begin- 
ner in  gynecological  work  is  bewildered  ])y  the  great  variety  of  specula,  tonacula 
and  other  instruments  for 
diagnosis,  and  he  is  ac- 
cordingly impressed  with 
the  idea  that  the  principal 
thing  is  to  learn  how  to 
use  instruments,  and  then 
to  use  them  on  every  oc- 
casion. One  of  the  first 
duties  of  a  teacher  in 
gynecology  is  to  displace 
this  erroneous  idea  by 
showing  the  importance 
of  the  use  of  the  hands. 
Most  of  the  serious  dis- 
eases of  women  affect 
structures  that  lie  beyond 
the  reach  of  sight.  To 
the  teacher  falls  the  duty 
of  directing  the  student's 
efforts  in  such  a  way  that 
he  will  acquire  the  abil- 
ity to  distinguish  these 
intrapelvic  conditions  in 
the  only  way  that  such 

conditions  can  be  distinguished,  namely,  by  touch.  After  the  student  has, 
by  lectures,  supplemented  by  charts  and  demonstrations,  been  helped  to  form  a 
mental  picture  of  the  normal  organs — their  position,  size,  shape,  structure  and 
relations — then  comes  the  task  of  helping  him  to  recognize  such  conditions  by 
the  sense  of  touch.  This  is  not  a  matter  of  a  few  days.  It  takes  weeks  and  months 
of  patient  work  and  many  careful  examinations,  to  be  able  to  recognize  norma! 
conditions.  The  abdominal  wall  and  the  vaginal  wall  intervene  between  the 
examining  fingers  and  the  important  organs.  These  intervening  structures  vary 
so  much  in  thickness,  in  consistency,  in  tension  and  in  sensitiveness,  that  there 
is  infinite  variety  in  the  facility  with  which  the  organs  may  be  outlined.  Again, 
the  organs  themselves  vary  much  within  normal  limits,  in  different  individuals 
and  in  the  same  individual  at  different  times. 


Fig.  84.  Mechod  of  determining  how  intimately  a  mass  is  attached  to 
the  uterus.  Palpating  the  sulcus  between  the  two.  (Kelly — Operative 
Gynecology.) 


68 


THE  PHYSICAL  EXAMINATION 


The  beginner  must  learn  to  read  the  conditions  first  by  learning  the  separate 
letters,  so  to  speak,  and  then  learning  what  certain  groupings  of  letters  mean.  The 
separate  items  that  must  be  recognized  in  this  examination  are  the  position,  size, 

shape,  consistency,  tenderness, 
mobility  and  attachments  of  the 
organs.  This  takes  much  time 
and  patience  and  well  directed 
efforts  through  many  examina- 
tions. It  cannot  be  learned 
from  lectures.  It  cannot  be 
learned  by  seeing  someone 
make  examinations  and  appli- 
cations. It  can  be  learned  only 
through  repeated  bimanual 
examinations  by  the  student 
himself,  under  competent  in- 
struction. Hence  the  import- 
ance of  the  clinical  portion  of 
a  gynecological  course. 

''Though  it  takes  consider- 
able time  to  learn  to  recognize 
normal  conditions,  the  time  is 
well  spent,  for  no  real  progress 
is  possible  without  this  knowl- 
edge. The  normal  must  be 
known  before  the  abnormal  can  be  appreciated.  This  is  self-evident  and  yet  how 
many  students  at  graduation,  and  physicians  long  after  graduation,  find  it  difficult 
to  feel  more  than  the  vaginal 
walls  and  cervix. 

''In  the  recognition  of 
pathological  conditions,  the 
same  points  must  be  consid- 
ered (position,  size,  shape, 
consistency,  tenderness,  mob- 
ility and  attachments),  and 
this  information,  supple- 
mented by  the  history,  de- 
termines tho  diagnosis. 
This  determination  of  the 
particular  pathological  con- 
ditions present  is  accom- 
plished almost  altogether  by 
the  hands,  either  in  the  ord- 
inary bimanual  examination 
or  in  the  examination  under 
anesthesia. 

/  ^  T    1  i      •   1     i  ...  I^'ig.  86.     Palpating    the 

I  do  not  wish  to    mmimize     Practice  of  Oynecologn.) 


Fig.  85.  Determining  what  attachment  there  is  between  the 
uterus  and  a  cyst  back  of  it.  The  uterus  is  caught  between  the 
hands  and  brought  forward  and  the  examining  fingers  are  crowded 
in  between  the  uterus  and  the  mass  {Aahton  — Practice  of  Gyn- 
ecology.) 


region    of  the    right  ureter.     (Ashton^ 


TRAIN  ONE  HAND 


69 


Deep  pptfcastric- 
-  -  Femoml  rin(f.-^ 
U*  lObtur.'forameil 


Middle  hem-   Vftg;-i# 


Fig.  87.  Showing  the  exact  situation  of  the  large  nerve  roots  in 
the  pelvis.  In  the  illustration  the  Itarge  nerve  roots  appear  a  shade 
darker  in  color  than  the  other  strustures.  (Kelly— Opei-aiive  Gyne- 
cology.) 


the  value  of  diagnostic  instruments  (specula,  sounds,  curets,  etc).  They  are 
often  helpful  and  in  some  cases  indispensable  to  a  positive  diagnosis,  and  their 
use  should  not  be  neg- 
lected. But  I  want  to  em- 
phasize the  fact  that  in 
gynecological  examina- 
tions generally,  instru- 
ments are  of  second- 
ary importance  and 
only  supplemental  to 
the  trained  hand." 

Take  every  opportun- 
ity to  educate  the  fingers 
to  appreciate  as  accurate- 
ly as  possible  the  various 
conditions  found  in  the 
pelvis.  When  examining 
a  suitable  case,  outline 
the  uterus  and  all  the 
pelvic  structures  as  clear- 
ly as  you  can,  even  if  not 
necessary  to  the  diagnosis 
in  that  particular  case. 
Each  careful  examination 

made  serves  to  educate  the  fingers,   or    rather  serves  to   educate  the  mind   to 

appreciate  what  is  between  the 
fingers,  and  prepares  you  to 
make  out  the  exact  conditions 
in  difficult  cases. 


Train  one  Hand. 

In  the  bimanual  examina- 
tion, it  is  well  to  train  one  hand 
for  the  vaginal  manipulations. 
For  this  purpose,  either  the 
right  or  the  left  hand  may  be 
selected,  as  the  examiner  finds 
more  convenient.  I  use  the 
left,  leaving  the  right  free  for 
the  abdominal  palpation  and 
for  the  handling  of  instruments. 
The  advantage  of  using  the 
same  hand  in  vaginal  manipu- 
lations in  practically  all  cases, 
is  that  the  power  of  discrimina- 
tion by  the  fingers  of  that  hand 


Fig.  88. 
(Dudley- 


Palpating     the      pelvic 
■Practice  of  Gynecology.) 


nerve    trunks    per     rectum. 


70  THE  PHYSICAL  EXAMINATION 

increases  as  more  and  more  examinations  are  made.  At  the  same  time,  the  ab- 
dominal hand  becomes  accustomed  to  the  abdominal  manipulations  and  as  the 
examining  hands  are  in  practically  the  same  relation  in  every  case,  deviations  from. 
the  normal  are  more  readily  recognized  and  more  accurately  defined  than  if  the 
two  hands  were  used  indiscriminately  and  hence  in  different  relations.  This4s 
especially  true  when  the  examiner  has  the  advantage  of  only  a  limited  number  of 
examinations. 

In  exceptional  cases,  it  is  an  advantage  to  use  first  one  hand  and  then  the  other 
for  vaginal  palpation.  In  some  cases,  the  right  side  of  the  pelvis  can  be  explored 
better  with  the  fingers  of  the  right  hand  and  the  left  side  with  the  fingers  of  the  left 
hand. 

Use  Two  Fingers. 

Use  two  fingers  in  the  vagina  when  the  vaginal  opening  is  large  enough  to  permit 
their  use  without  pain.  A  deeper  and  more  accurate  examination  can  be  made 
with  two  fingers  (index  and  middle  finger)  than  with  the  index  finger  alone.  The 
upper  part  of  the  vagina  is  capacious.  The  only  difficulty  is  at  the  vaginal  en- 
trance. By  lubricating  the  fingers  well,  and  depressing  the  perineum  and  working 
carefully,  the  two  fingers  may  be  used  without  discomfort  in  practically  all  parous 
women,  and  in  most  non-parous  women  who  havD  been  married. 

Examine  Deeply  in  Pelvis. 

In  many  cases,  in  order  to  palpate  the  posterior  part  of  the  pelvis  and  particu- 
larly to  satisfactorily  palpate  the  tubo-ovarian  regions,  the  vaginal  fingers  must 
reach  farther  than  their  length  will  permit.  The  extra  reach  is  secured  by  carrying 
the  perineum  into  the  pelvis  (invagination  of  the  pelvic  fioor)  by  strong  steady  pres- 
sure inward.  The  soft  structures  closing  the  pelvic  outlet  can  be  carried  for  a  con- 
siderable distance  inward  without  particular  discomfort  to  the  patient,  provided 
all  the  muscles  are  relaxed.  In  parous  women,  from  one  to  two  inches  may  usually 
be  thus  added  to  the  effective  length  of  the  examining  fingers. 

The  force  required,  while  not  great,  is  likely,  if  exerted  by  the  arm  muscles  alone, 
to  interfere  with  delicate  palpation  by  the  examining  fingers.  It  adds  much  to  the 
effectiveness  of  the  examination  to  exert  this  pressure  by  the  body  muscles,  leaving 
the  arm  muscles  free  for  the  internal  palpation  movements.  This  may  be  accom- 
plished either  by  placing  the  left  foot  (when  examining  with  the  left  hand)  on  a 
stool  or  chair-round  and  resting  the  elbow  on  the  knee  (Figs.  75,  76),  or  by  letting 
the  elbow  rest  against  the  hip  (Fig.  77). 

May  Draw  the  Uterus  Down. 

It  is  advantageous  in  the  bimanual  examination  in  some  cases,  to  catch  the  cer- 
vix with  the  tenaculum  forceps  and  draw  the  uterus  downward,  so  that  the  exam- 
ining fingers  may  reach  higher  on  its  posterior  surface  (Fig.  74) .  This  is  useful  in 
those  cases  where  the  uterus  lies  so  far  back  in  the  pelvis  that  it  is  difficult  to  reacli. 
After  making  the  vagino-abdominal  examination  in  the  usual  way,  the  tenaculum 
may  then  be  introduced  by  touch  and  the  cervix  caught  and  Ijrought  down, 


POSITION  FOR  EXAMINER  71 

Only  light  traction  should  be  made — not  enough  to  unduly  stretch  the  sacro-uter- 
ine  ligaments,  which  might  lead  to  subsequent  trouble.  I  want  to  protest  against 
the  statement  made  l)y  some  authorities  to  the  effect  that  the  normal  uterus  may 
with  impunity  be  pulled  down  until  the  cervix  appears  at  the  vaginal  opening,  or 
may  without  harm  be  turned  into  extreme  retroversion,  for  the  pui-pose  of  palpating 
the  posterior  surface  or  even  hooking  a  finger  in  the  rectum  over  the  fundus  and  pal- 
pating the  anterior  surface.  The  uterus  is  usually  mova])le  in  all  directions,  but  the 
movements  here  mentioned  are  far  beyond  the  normal  range  and  can  l)e  accom- 
plished only  i)y  undue  stretching  of  the  structures  intended  to  prevent  such  dis- 
placements. 

Of  course,  when  the  pelvic  structures  are  already  overstretched  and  lax,  as  in 
cases  ot  laceration  of  the  pelvic  floor  with  descent  of  the  uterus  or  in  cases  of  mov- 
able retrodisplacement,  these  extreme  maneuvers  may  be  carried  out  without  further 
damage,  and,  in  doubtful  cases,  with  great  advantage  in  regard  to  accuracy  of  diag- 
nosis. In  a  patient  with  practically  normal  uterine  supports,  however,  the  pulling 
down  of  the  uterus  or  the  backward  displacement  of  the  uterus  for  diagnostic  pur- 
poses or  for  therapeutic  purposes  (as  in  curetment  or  repair  of  cervix),  should  be  of 
ver}'  limited  extent.  It  is  easy  to  overstretch  the  uterine  supports  but  it  is  not  so 
easy  to  restore  tone  to  these  structures  so  that  they  will  again  hold  the  uterus  in 
just  the  right  way.  This  is  particularly  important  in  regard  to  the  postcervical 
supports  (sacro-uterine  ligaments  and  adjacent  tissues)  which  are  stretched  every 
time  the  cervix  is  pulled  downward.  When  these  are  once  over-stretched  and 
rendered  lax,  it  is  practically  impossible  to  keep  the  uterus  permanently  in  proper 
position  except  by  operation. 

Preferable  Position  for  Examiner. 

For  the  vaginal  and  bimanual  examinations,  it  is  decidedly  advantageous  for  the 
examiner  to  stand  directly  in  front  of  the  vaginal  opening,  as  shown  in  Fig.  75. 
This  is  especially  important  when  very  deep  pelvic  palpation  is  necessary.  This 
is  the  usual  position  when  the  patient  is  examined  on  the  table  with  foot-rests  so 
that  the  hips  may  be  brought  entirely  to  the  end  of  the  table. 

When  a  patient  is  examined  in  bed,  however,  the  usual  directions  are  to  pass  the 
examining  arm  under  one  thigh.  This  puts  the  examining  arm  and  hand  at  a  de- 
cided disadvantage.  The  examiner  should  sit  so  that  the  examining  arm  passes 
between  the  thighs  as  shown  in  Fig.  114.  This  puts  the  arm  directly  in  front  of  the 
genitals,  the  same  as  in  the  examination  on  the  table.  This  brings  the  arm  and 
hand  in  the  most  advantageous  position  for  accurate  palpation  deep  in  the  pelvis, 
as  the  reader  can  easily  demonstrate  to  his  own  satisfaction  by  giving  a  trial  of  each 
method  in  some  difficult  case  requiring  deep  palpation. 

Conditions  in  Different  Patients. 

The  facility  with  which  the  bimanual  examination  can  be  made  varies  much  in 
different  patients.  In  some,  tlie  fingers  on  entering  the  vagina  are  checked  by  the 
strong  contraction  of  the  muscles  of  the  pelvic  floor.  When  such  is  the  case,  turn 
the  ofllmar  surface  of  the  examining  fingers  backward  and  make  steady  pressure 


72  THE  PHYSICAL  EXAMINATION 

against  the  posterior  vaginal  wall  and  the  contracting  muscles.  This  gives  you  an 
idea  of  the  strength  of  the  muscles  of  the  pelvic  floor  and  soon,  under  the  pressure, 
the  muscles  relax.  Another  troublesome  obstacle  to  deep  bimanual  examination 
is  tension  of  the  abdominal  wall.  The  methods  of  overcoming  this  have  already 
been  explained. 

In  a  thin  patient,  with  a  large  vagina  and  a  relaxed  abdominal  wall,  the  uterus 
can  be  outlined  and  the  appendages  felt,  and  any  abnormal  mass,  even  a  small  one, 
can  be  satisfactorily  palpated. 

In  a  stout  patient,  with  a  thick  layer  of  fat  over  the  abdomen,  the  ordinary  bi- 
manual examination  is  often  unsatisfactory,  particularly  if  there  is  inflammatory 
trouble  with  tension  of  the  abdominal  wall.  In  such  a  case,  a  mass  of  considerable 
size,  if  situated  high  in  the  pelvis,  may  be  missed  entirely.  The  only  way  to  de- 
termine exactly  the  pelvic  contents  in  such  a  case  is  to  make  an  examination  under 
anesthesia.  Such  an  examination  should  be  made  in  those  cases  where  the  symp- 
toms are  urgent  enough  to  make  an  immediate  accurate  diagnosis  necessary. 


Get  Intestines  Out  of  the  Way. 

In  some  cases,  particularly  when  there  is  considerable  tympanites,  distended 
coils  of  intestine  interfere  with  the  bimanual  palpation  of  the  pelvic  structures. 

To  overcome  this  difficulty,  elevate  the  patient's  hips  into  the  Trendelenburg  pos- 
ture. Then  work  the  intestines  out  of  the  pelvis  and  hold  them  out  as  the  hips  are 
slowly  lowered  into  a  more  comfortable  position.  Leave  the  hips  rather  high,  as 
high  as  the  patient  will  stand  without  discomfort,  and  direct  her  to  keep  all  the 
rnuscles  loose  and  breathe  quietly,  so  as  not  to  force  the  intestinal  coils  back  into 
the  pelvis.  The  regular  bimanual  palpation  may  then  be  carried  out,  undisturbed 
by  the  troublesome  intestinal  coils. 

This  is  a  very  convenient  maneuver  also  for  getting  a  pediculated  tumor  out  of 
the  pelvis,  that  its  pedicle  and  point  of  origin  may  be  accurately  determined  by 
bimanual  palpation. 

In  case  the  table  is  not  arranged  for  the  convenient  elevation  of  the  hips,  the  hips 
may  be  elevated  by  means  of  pillows  or  the  patient  may  be  placed  in  the  knee=chest 
posture  for  a  few  moments.  With  the  clothing  well  loosened  and  the  correct  knee- 
chest  posture  assumed,  the  distended  intestinal  coils  fall  out  of  the  pelvis  better  than 
in  the  Trendelenburg  posture,  but  in  the  exertion  of  assuming  the  dorsal  posture 
again  they  are  likely  to  be  partially  forced  back.  Avoid  this  as  much  as  possible  by 
directing  the  patient  to  keep  the  upper  part  of  the  body  on  the  table  (not  to  raise  it, 
as  in  partly  sitting  up)  and  to  keep  the  abdominal  muscles  loose.  Also  place  a  thick 
pillow  under  the  hips,  as  the  dorsal  posture  is  assumed.  An  additional  expedient 
is  to  put  a  speculum  in  the  vagina  and  in  the  rectum  while  the  patient  is  in  the  knee- 
chest  posture.  The  vagina  and  rectum  then  balloon  with  air,  forcing  the  intes- 
tinal coils  out  of  the  pelvis.  The  specula  are  then  removed  and  the  openings  close, 
retaining  the  air  which  helps  to  keep  the  intestinal  coils  out  of  the  pelvis  in  the  sub- 
sequent movements. 


PALPATION    PER  UKCTUM  73 

Diminish  Tenderness. 

In  many  patients  satisfactory  pelvic  exploration  is  prevented  by  tenderness,  par- 
ticularly in  that  large  class  of  cases  in  which  pelvic  inflammation  is  a  primary  or 
complicating  lesion.  In  some  of  these  cases  the  symptoms  are  so  urgent  that  an 
examination  under  anesthesia  at  once  is  advisable.  In  most  of  the  cases,  however, 
the  symptoms  are  not  so  threatening  as  to  necessitate  immediate  examination  under 
anesthesia.  The  patient,  has  come  for  a  diagnosis  but  an  accurate  diagnosis  can 
not  be  made  because  of  the  tenderness  which  prevents  deep  palpation.  What  shall 
the  examiner  do  under  these  circumstances?  There  are  two  measures  which  are 
useful  in  diminishing  the  tenderness  and  abdominal  tension. 

'  1.  Administration  of  a  sedative.  The  patient  may  be  given  J-  gr.  of  codeine  phos- 
phate hypodermatieally,  or  J-  gr.  or  i  gr.  of  morphia,  and  examined  again  after  half 
an  hour. 

If  thought  preferable,  an  appointment  ma}"  be  made  for  the  next  day  and  an 
order  given  for  the  sedative  to  be  taken  Ijy  mouth  one  hour  before  your  visit.  In 
the  meantime  the  patient  is  kept  quiet  in  bed  and  the  bowels  well  opened.  It  is 
well  to  have  an  enema  given  half  an  hour  before  examination. 

2.  Treatment  for  the  inflammation.     The  patient  is  kept  in  bed,  the  bowels  well^ 
opened,  hot  vaginal  douches  given  and  the  regular  treatment  for  acute  or  subacute 
pelvic  inflammation  carried  out     This  treatment  continued  for  a  few  days  or  a 
week  T\dll  do  much  toward  diminishing  the  tenderness,  so  that  a  thorough  pelvic 
examination  mav  be  made. 


RECTO=ABDOMINAL  PALPATION. 

In  many  cases  it  is  of  decided  advantage  to  follow  the  vagino-abdominal  exam- 
ination by  a  recto-abdominal  examination.  In  this  form  of  bimanual  examination, 
the  index-finger,  gloved  and  lubricated,  is  introduced  into  the  rectum  and  passed 
upward  betw^een  the  sacro-uterine  ligaments  as  far  as  possible  up  the  posterior  sur- 
face of  the  uterus.  With  the  fingers  of  the  other  hand  pressing  down  the  organs 
from  above,  all  the  structures  within  reach  are  palpated  with  the  palmar  surface  of 
the  rectal  finger  (Fig.  102). 

Disadvantages. 

Ordinarily,  palpation  of  the  pelvic  structures  may  be  carried  out  much  more 
thoroughly  by  vagino-abdominal  examination  than  by  recto-abdominal  examina- 
tion. Without  anesthesia  but  one  finger  can  be  used  in  the  rectum  and  this  finger 
lies  at  a  considerable  distance  from  the  uterus  and  adnexa,  unless  carried  very  high. 
It  cannot  usually  be  carried  very  high  on  account  of  the  encircling  sphincter  and 
pelvic  floor,  except  by  the  use  of  such  force  as  to  cause  pain  and  resistance.  In 
some  cases  where  the  pelvic  floor  is  lax,  the  examining  hand  may  easily  carry  the 
peri-anal  structures  some  distance  into  the  pelvis,  thus  allowing  the  examining  finger 
to  pass  high  up  back  of  the  uterus  and  permitting  accurate  bimanual  palpation  of 
the  adnexa.     The  facility  with  which  the  organs  may  be  felt  is  increased  by  catching 


74  THE  PHYSICAL  EXAMINATION 

1 

the  cervix  -v^-ith  a  tenaculum  forceps  and  bringing  the  uterus  somewhat  lower.     In      ■ 
all  but  exceptional  cases,  however,  accurate  examination  of  the  pelvic  contents  by 
recto-abdominal  palpation  is  practicable  only  under  anesthesia.     However,  such 
palpation  as  can  be  carried  out  without  anesthesia  gives  information  of  value  -in 
some  cases,  as  indicated  in  the  following  paragraphs. 

When  Useful. 

It  is  well  to  employ  digital  examination  per  rectum,  or  conjoined  (bimanual) 
recto-abdominal  palpation,  in  the  following  cases: 

Mass  in  Cul=de=sac.  Rectal  palpation  is  useful  when  there  is  a  mass  of  inflam- 
matory exudate  or  a  tumor  low  in  the  peritoneal  cul-de-sac  back  of  the  uterus.  In 
the  case  of  an  inflammatoiy  mass  in  that  situation,  fluctuation  may  be  in  some 
cases  detected  while  it  is  not  yet  appreciable  by  vaginal  examination. 

Malignant  Infiltration.  In  malignant  disease  of  the  cervix  extending  out  into 
the  parametrium,  rectal  palpation  will  in  some  cases  give  additional  information 
as  to  the  extent  of  the  infiltration  and  the  mobility  or  fixation  of  the  uterus. 

Rectal  Disease.  When  a  patient  gives  symptoms  pointing  to  rectal  disease,  the 
rectum  should  of  course  be  examined  by  palpation  and  also  by  inspection  through 
rectal  speculum  if  necessary  to  determine  the  exact  condition. 

Obscure  Cases.  In  cases  where  the  other  methods  do  not  show  lesions  suffi- 
cient to  account  for  the  symptoms,  a  rectal  examination  should  be  made  to  de- 
termine if  there  is  any  rectal  or  perirectal  disease  that  might  account  for  the  pelvic 
pain  and  distress. 

Occasionally  in  a  Virgin.  The  information  concerning  the  uterus  and  adnexa 
thus  obtained  is  usually  very  indefinite,  as  explained  below.  In  such  examination 
the  landmark  is  the  ceindx  uteri,  which  maj^  be  easilj^  felt  through  the  rectal 
wall.  Notice  if  there  is  a  distinct  mass  back  of  the  cervix  (inflammatory  mass, 
tumor,  fundus  uteri  in  retrodi-splacement)  or  a  point  of  special  tenderness  anywhere 
in  the  lower  part  of  the  j^elvis. 


BIMANUAL  EXAMINATION  OF  A  VIRGIN. 

As  previously  explained,  local  examination  in  the  case  of  a  virgin  is  to  be  avoided 
if  possible.  When  it  is  necessar}^  to  make  an  intrapelvic  examination,  what  method 
should  be  used? 

The  direction  has  been  given,  in  various  works,  to  examine  virgins  by  the  rectum 
when  it  is  necessary  to  determine  the  condition  of  the  uterus  or  adnexa,  in  order 
to  avoid  stretching  the  hymen.  In  a  virgin  those  conditions  which  militate  against 
a  satisfactoiy  palpation  of  the  uterus  and  adnexa  by  recto-abdominal  examination, 
are  at  their  height.  Usuallj^  after  such  an  examination  without  anesthesia  the 
examiner  knows  but  little  more  concerning  the  uterus  and  adnexa  than  he  did 
before  the  examination.  Of  course  if  there  is  a  good  sized  mass  low  in  the  pelvis 
or  a  particularly  tender  area,  its  presence  is  determined.  But  the  information  is 
usually  too  indefinite  for  an  exact  diagnosis.     Such  an  examination  does   very  well 


EXAMINATION  OF  A  VIRGIN  75 

however,  to  "break  the  ice"  so  to  speak,  and  it  may  be  explained  then  that  the 
conditions  are  such  that  a  vaginal  examination  is  advisable.  In  some  cases  the 
recto-abdominal  examination  is  very  satisfactory,  the  required  information  being 
obtained  with  fair  accuracy. 

In  the  rectal  palpation,  the  cervix  uteri  can  be  felt  through  the  rectal  wall. 
If  there  is  no  mass  back  of  the  cervix  (inflammatory  mass  or  tumor  or  fundus 
uteri  deep  in  cul-de-sac)  and  no  area  of  particular  tenderness  in  the  pelvis,  it  may 
be  advisable  to  postpone  further  local  examination  and  try  general  therapeutic 
measures  for  several  weeks  or  months. 

Usually,  however,  when  the  symptoms  are  severe  enough  to  warrant  any  local 
examination,  they  are  severe  enough  to  warrant  a  recto-abdominal  examination 
under  anesthesia,  or  a  stretching  of  the  hymen  sufficiently  to  admit  one  finger,  so 
that  the  regular  vaginal  and  vaginal-al^dominal  examination  may  he  made.  The 
condition  of  the  uterus  and  the  adnexa  may  be  much  more  definitely  determined 
in  this  way  than  by  rectal  palpation. 

In  a  large  proportion  of  virgins,  even  the  regular  vagino-abdominal  palpation 
does  not  permit  accurate  outlining  of  the  uterus  or  of  adnexal  masses.  Conse- 
quently, in  the  case  of  a  virgin  where  there  is  serious  pelvic  trouljle  necessitating  an 
accurate  palpation  of  the  pelvic  contents,  an  examination  under  anesthesia  is 
usually  required.  In  cases  where  the  necessity  of  a  thorough  pelvic  examination 
is  apparent  from  the  first,  it  is  preferable,  in  a  girl  or  a  young  unmarried  woman,  to 
at  once  examine  the  patient  under  an  anesthetic.  This  eliminates  the  mental  shock 
of  the  procedure  and  at  the  same  time  permits  a  thorough  exploration.  It  is  v/ell 
to  employ  recto-abdominal  palpation  first  and  then,  if  necessary,  vagino-abdo- 
minal palpation.  In  addition,  any  operative  measure  required  for  diagnostic  or 
therapeutic  purposes,  may  be  carried  out,  for  example,  dilatation  and  curetment 
ol  uterus  or  removal  of  hemorrhoids. 


RECTO=VAQINO=ABDOMINAL  PALPATION. 

In  exceptional  cases  when  making  the  recto-abdominal  examination,  it  is 
advantageous  to  introduce  the  thumb  into  the  vagina  in  order  to  grasp  the  lower 
part  of  a  mass  between  the  finger  in  the  rectum  and  the  thumb  in  the  upper  part  of 
the  vaginal  canal,  the  structure  being  pushed  down  \\-ithin  reach  by  the  abdominal 
hand  (recto-vagino-abdominal  palpation).  Where  a  mass  is  low  enough  to  be 
grasped  in  this  way,  its  outline  and  consistency  can  be  very  accurately  determined. 
It  is  only  in  the  cases  of  large  vaginal  opening  and  relaxed  floor  that  this  method  is 
applicable,  and  to  be  of  much  service  anesthesia  is  usually  required.  Occasion- 
ally, however,  it  is  useful  in  the  ordinary  examination. 

I  recall  in  particular  one  puzzling  case,  that  was  referred  to  me  for  differential 
diagnosis,  in  which  this  maneuver  was  of  much  assistance.  The  patient  presented 
a  mass  of  moderate  size,  pretty  well  filling  the  pelvis.  The  mass  contained  fluid, 
the  cervix  was  somewhat  softened  and  the  uterine  body  could  not  be  definitely 
locatel.  The  differentiation  was  between  an  enlarged  uterus  containing  fluid 
(normal  or  abnormal  pregnancy)  and  .some  other  fluid  mass  (cystic  fibroid,  extra- 


76 


THE  PHYSICAL  EXAMINATION 


uterine  pregnancy,  hydrosalpinx,  ovarian  or  parovarian  cyst).  The  history  was 
uncertain  and  the  findings  in  the  ordinary  examination  were  not  positive.  The 
crucial  point  was  to  identify  the  body  of  the  uterus.  Was  this  large  mass  the  body 
of  the  uterus  enlarged  (pregnancy)  or  was  the  body  of  the  uterus  of  practically 
normal  size  and  located  somewhere  in  the  mass? 

Sounding  of  the  uterine  canal  was  not  permissible  until  pregnancy  could  be 
excluded.  The  lower  posterior  part  of  the  large  mass  presented  a  small  firm 
portion,  which  might  be  the  normal-sized  body  of  the  uterus  displaced  or 
simply  a  firm  portion  of  an  enlarged  uterus.  The  firm  area  was  so  cov- 
ered over  and  surrounded  by  the  mass  that  I  could  not  make  satisfactory  bi- 
manual palation  of  it,  neither  could  I  definitely  outline  it  through  a  sufficient 
extent  by  either  vaginal  or  rectal  palpation.  Finally  I  tried  to  grasp  this  firm 
portion  of  the  mass  between  the  finger  in  the  rectum  and  the  thumb  in  the  vagina. 
As  the  vaginal  opening  and  pelvic  floor  were  lax,  I  could  carry  the  thumb  to  the 
top  of  the  vagina  without  much  discomfort  to  the  patient,  ao  .  by  crowding  the 


Fig.  89.     Method  of  palpating  the  coccyx.     The  hand  should  be  gloved. 
(Hirst  —  Diseases  of  Wornen.) 


mass  down  with  the  abdominal  hand,  I  was  able  to  grasp  the  firm  portion 
between  the  finger  and  the  thumb  of  the  left  hand  and  separate  it  from  the  fluid 
mass  sufficiently  to  trace  its  outhne  and  get  the  consistency  throughout.  It  was 
of  about  the  size,  shape  and  consistency  of  the  normal  uterus,  and  by  working  the 
finger  and  thumb  toward  each  other  above  this  firm  part,  I  could  demonstrate  that 
the  fluid  portion  of  the  mass  had  a  separate  wall.  I  now  felt  safe  in  introducing 
the  sound,  which  confirmed  the  palpation  findings.  This  firm  area  was  the  dis- 
placed body  of  the  uterus,  otherwise  practically  normal,  and  the  surrounding  fluid 
mass  was  a  separate  affair,  an  ovarian  or  parovarian  c)'st. 

A  modification  of  this  method  is  to  introduce  the  middle  finger  into  the  rectum 
and  the  index  finger  into  the  vagina  and  palpate  the  structures  between  the  fingers, 


THE  Sl'ECULUM  ]0XAM1  NATION  77 

as  the  uterus  is  pushed  down  from  above.  This  particular  method  of  recto-vagino- 
abdominal  palpation  has  been  found  useful  in  determining  the  extent  of  involv- 
ment  of  the  parametrium  in  cases  of  carcinoma  of  the  cervix  uteri. 

PALPATION  OF  COCCYX. 

In  cases  of  persistent  pelvic  pain  where  no  sufficient  cause  is  found  about  the 
uterus  or  adnexa,  the  coccyx  should  be  palpated.  This  small  bone  at  the  tip  of  the 
sacrum  is  not  infrequently  the  site  of  neuralgia  or  rheumatism  (affecting  the  joints 
or  adjacent  muscles)  or  a  chronic  inflammation  resulting  from  an  injury  sustained 
months  or  years  l:)efore.  These  injuries  usually  can  be  traced  to  child-birth 
though  occasionally  such  a  condition  will  result  from  a  fall  or  blow.  In  rare 
cases,  neuralgia  or  rheumatism  or  inflammation  may  become  manifest  here  without 
previous  injury.  Tenderness  of  the  coccyx  or  a  mass  about  any  portion  of  it  or 
a  deformity,  may  be  easily  determined  by  an  examination  with  the  index  finger 
(gloved)  in  the  rectum  and  the  thumb  over  the  coccyx  (Fig.  89).  The  examina- 
tion is  most  conveniently  made  with  the  patient  lying  on  her  side.  In  this  way 
the  coccyx  may  be  accurately  outlined  and  any  deviation  from  the  normal  de- 
termined. In  some  cases  the  coccyx  appears  to  be  normal  until  an  attempt  is 
made  to  move  it,  when  there  is  severe  pain,  indicating  trouble  in  the  joint  or 
about  the  fasciae  or  muscles. 


INSTRUMENTAL  EXAMINATION. 

This  term  includes  those  manipulations  in  which  it  is  necessary  to  use  instru- 
ments.    Coming  under  this  classification  are  the  following: 

Inspection  of  Vagina  and  Cervix  through  the  Speculum   (Speculum 

Examination) . 
Excision  of  Tissue  from  Cervix  for  Microscopic  ExaminatioHo 
Exploration  of  Interior  of  Uterus  with  the  Sound. 
Exploration  of  Interior  of  Uterus  with  the  Curet. 

SPECULUM  EXAMINATION. 

By  means  of  certain  instruments  the  vaginal  walls  may  be  spread  apart  so  that 
those  walls  and  the  cervix  uteri  may  be  seen.  Information  of  much  value  in  some 
cases  may  be  obtained  in  this  way. 

Instruments  for  Regular  Speculum  Examination. 

The  instruments  needed  for  this  examination  are  shown  in  Fig.  90.  They  are 
as  follows: 

A  Speculum  for  separating  the  vaginal  walls; 

A  long  Dressing  Forceps  for  sponging  out  the  vagina,  usually  called 

"Uterine  dressing  forceps;" 
A  Tenaculum  Forceps,  or  "Volsellum,"  for  catching  the  cervix  and 

bringing  it  better  into  view. 
A  Specimen  Scissors. 


78 


THE  PHYSICAL  EXAMINATION 


Vaginal  Speculum.  The  bivalve  speculum  (Fig.  90-a)  is  the  kind  most  fre- 
quently used  in  ordinary  office  work.  It  consists  of  two  blades,  which  are  intro- 
duced closed  and  then  opened  by  a  mechanism  at  the  handle.  The  vaginal  walls 
are  thus  held  apart  (Fig.  91)  and  a  very  good  view  of  the  walls  and  cervix  may  be 
obtained.  The  bivalve  speculum  is  convenient  and  gives  good  exposure  of  the 
cervix  in  most  cases. 

There  are  many  different  modifications  of  the  blades  and  also  of  the  mechanism 
for  separating  the  blades.  The  most  satisfactory  form  that  I  have  found  is  shown 
in  the  illustration.  It  is  called  the  Graves  speculum  and  has  the  advantage  that 
it  can  be  easily  and  quickly  transformed  into  a  fairly  satisfactory  Sims'  speculum, 


Fig.  90.  Instruments  for  the  regular  speculum  examination,  a.  Bivalve  Speculum,  of  which  it  is  well 
to  have  three  sizes— large,  medium  and  small,  b.  Dressing  Forceps  for  swabbing  out  vagina,  c.  Tena- 
culum-forceps  for  catching  cervix  to  bring  it  well  into  view.  b.  Specimen  Scissors,  a  small  strong  hawk  bill 
scissors  for  clipping  small  specimens  from  the  cervix  in  susyicious  cases. 


which  is  a  decided  convenience  in  office  work.  Three  sizes  are  useful — small 
(virgin),  medium  and  large.  The  cervix  is  easier  exposed  in  most  cases  if  the  an- 
terior blade  of  the  speculum  is  somewhat  shorter  than  the  posterior. 

Some  specula  are  made  with  three  blades,  instead  of  two,  constituting  a  tri- 
valve  speculum.  They  are  made. on  the  same  general  principles  as  the  bivalve 
but  the  mechanism  is  more  complicated  and,  usually,  without  corresponding 
benefit. 

The  bivalve  speculum  is  used  with  the  patient  in  the  dorsal  posture  (Fig.  41). 
For  sterilization  of  specula  and  other  instruments,  see  Preparations  for  Exami- 
nation, at  the  end  of  this  chaptero 


THE  BIVALVE  SPECULUM 


79 


The  uterine  dressing=forceps  (Fig.  90-b)  is  a  long  strong  forceps  for  sponging  out 
the  vagina  and  for  making  vaginal  applications.  It  may  be  straight  or  curved 
as  preferred.  I  find  the  forceps  with  a  straight  shank  and  a  slight  curve  near  the 
end  more  convenient  than  the  much  curved  instrument.  A  vaginal  depressor  for 
pushing  the  vaginal  wall  out  of  the  way  is  usually  mentioned  in  an  examining  set 


Fig.  9L     Bivalve  Speculum   in  place.     Sectional  view,  showing  relations  of  speculum  and  exposure  oi 
the  cervix  and  vaginal  vault  by  opening  the  blades. 


but  it  is  generally  not  necessary,  as  the  vaginal  wall  may  be  pushed  aside  sufficiently 
with  the  dressing-forceps. 

The  uterine  tenaculum=forceps  is  needed  for  catching  the  cervix  and,  bringing  all 
parts  of  it  into  view.  It  should  be  light  but  strong,  especially  about  the  lock, 
K'here  it  is  Hkely  to  work  loose  (Fig.  90-c) . 


80  THE  PHYSICAL  EXAMIXATION 

The  specimen  scissors  are  for  clipping  out  a  small  piece  of  tissue  from  the  cervix, 
in  cases  presenting  an  appearance  suspicious  of  mahgnant  disease.  The  one  shown 
in  Fig.  90-cl  I  have  found  very  convenient  and  satisfactorJ^  It  presents  at  the 
end  a  small  sharp  ''hawk-bill"  -^^liich  cuts  through  the  firmest  tissue,  clipping  out 
a  small  piece  "udth  but  little  pain  or  bleeding.  I  appropriated  it  from  the  throat 
specialist's  armamentarium,  where  it  is  catalogued  as  the  Miles  tonsil  punch. 


Steps  in  the  Regular  Speculum  Examination. 

Introducing  the  Speculum.  The  blades  of  the  speculum  are  closed  and  the  outer 
surfaces  lubricated  and  the  speculum  held  in  the  right  hand,  while  with  the  other 
hand  the  labia  are  separated  and  the  perineum     depressed  somewhat    with  one 

finger  (Fig.  92).  The  speculum  is 
then  introduced  and  carried  all  the 
way  to  the  upper  end  of  the  vagina 
T^ithout  being  opened.  In  most 
cases  the  speculum  passes  the  vagin- 
al entrance  most  easily  when  held 
with  its  width  almost  vertical,  the 
edge  being  held  just  far  enough  to 
one  side  to  miss  the  urethra  (Fig. 
93).  When  well  within  the  vagina, 
it  is  turned  transversely  and  carried 
in  as  far  as  it  "v\ill  go  (Fig.  94). 

Care  is  necessary  that  painful  pres- 
sure be  not  made  on  the  urethra  or 
other  structures  beneath  the  pubic 
arch.  Remember  that  when  more 
room  is  required,  the  pressure  must 
alwa3's  be  directed  against  the  per= 
ineum,  which  mil  gradually  yield. 
Another  common  mistake  with 
the  inexperienced  is  to  open  the 
blades  too  soon^  before  the  speculum 
has  been  introduced  all  the  way.  The  blades  are  not  in  far  enough  to  satis- 
factorily expose  the  cervix  and  in  closing  them  again  for  further  introduction, 
pain  is  likely  to  be  produced  by  pinching  the  vaginal  wall. 

Exposing  the  Cervix.  After  the  blades  have  been  introduced  well  up  to  the  top 
of  the  vagina,  they  are  opened  and  the  cervix  and  vaginal  walls  exposed  (Fig. 
91).  By  turning  the  speculum  in  various  directions,  all  parts  of  the  cer\dx  and 
upper  end  of  the  vagina  may  be  seen.  If  the  cervix  does  not  come  well  into  view 
it  may  be  caught  vnth  a  tenaculum  forceps  and  brought  downward  somewhat 
and  turned  from  side' to  side,  exposing  all  portions  of  it  and  of  the  vaginal  vault. 

Cleansing,  the  Vagina.  If  there  is  secretion  obscuring  any  part  of  the  vaginal 
wall  or  cer\-ix,  wipe  it  away  with  cotton  held  in  the  dressing-forceps  and  dipped 
in  an  antiseptic  solution. 


Fig.  92.  Introducing  the  bivalve  speculum.  First 
step  —  depressing  the  perineum  to  give  room  for  the 
speculum  to  be  introduced. 


THE  INFORMATION  T(J  BE  OUTAINKI) 


S'x 


Exposing  Lower  Portion  of  Vaginal  Walls.  To  inspect  the  middle  and  lower 
portions  of  the  vaginal  walls,  turn  the  speculum  so  as  to  bring  the  various  portions 
of  the  walls  opposite  the  opening  between  the  blades.  Another  way  is  to  inspect 
ihe  various  portions  of  the  walls  just  beyond  the  end  of  the  speculum,  as  it  is 
withdra^\^l.  Specula  with  skeleton  blades  are  made,  but  they  are  not  necessary 
and  ordinarily  they  are  likely  to  prove  unsatisfactory  in  a  good  many  cases 
l^ecause  of  the  prolapsing  of  the  redundant  vaginal  walls  through  the  large 
openings. 


Fig.  93.  Introducing  speculum.  It  has  been  car- 
ried part  way  in.  Notice  the  oblique  position,  which 
prevents  painful  pressure  on  the  urethra. 


Fig.  94.     The  speculum   carried  all    the  way  in   and 
turned  into  position  for  opening. 


Information  Obtained  in  the  Speculum  Examination. 

The  information  sought  in  the  speculum  examination  is  obtained  by  inspection 
of  the  following  structures: 

Vaginal  Walls — Color,  Discharge,  Redundancy; 

Cervix  Uteri^Position,  Color,  Size  and  Shape,  Lacerations,  Deviation 

of  Axis,  Eversion,  Erosion,  Hypertrophy,  Cystic  Change,  Ulcer; 
External  Os— Size  and  Shape,  Color  of  Edges,  Discharge,  Polypi. 

Vaginal  Walls.  Are  the  walls  of  normal  color  or  is  there  congestion?  If  con- 
gestion, is  it  active  or  passive?  If  the  walls  are  bright  red,  that  means  active 
or  arterial  congestion  and  is  due  to  inflammation  or  irritation.  If  the  walls  have  a 
bluish  tinge,  that  means  passive  or  venous  congestion  and  indicates  either  preg- 


S2  THE  PHYSICAL  EXAMINATION 

nancy  or  some  interference  with  the  circulation,  as  by  a  pelvic  tumor  or  exudate 
or  by  failure  in  compensation  in  heart  disease. 

If  there  is  discharge,  determine  whether  it  originates  in  the  vagina  or  in  the 
uterus.  If  the  vaginal  walls  are  lax  and  redundant,  they  tend  to  collapse  about 
the  speculum. 

Cervix  Uteri.  Is  the  cervix  in  low  position,  so  that  it  is  easily  exposed  when  the 
speculum  is  in  but  a  short  distance,  or  is  it  higher  than  normal,  so  that  it  cannot  be 
well  exposed  vnth  the  speculum  of  ordinary  length?  Is  the  color  normal  or  is  there 
congestion,  either  active  or  passive?  Here,  as  in  the  vaginal  wall,  active  conges- 
tion means  inflammation  or  irritation  and  passive  congestion  indicates  either 
pregnancy  or  obstruction  of  the  circulation.  A  bright  red  area  extending  a  con- 
siderable distance  out  from  the  os,  is  usually  due  to  the  peculiar  condition  called 
"erosion. ' ' 

In  regard  to  the  size  and  shape,  inspection  may  show  the  cervix  to  be: 

Normal. 
Long  Conical. 

Lacerated,  but  largely  united  again. 
Lacerated  and  not  united,  but  "without  complications. 
Lacerated  and  everted,  eroded,  hypertrophied,  or  ^ith.  cystic  change 
or  wdth  a  genuine  ulcer. 

Is  the  axis  of  the  cervix  directed  across  the  vagina,  as  it  should  be  normally,  or 
ALONG  the  vagina,  as  in  retrodisplacement  of  uterus  or  anteflexion  of  cer\'ix? 

External  Os.  The  size  and  shape  show  whether  or  not  there  has  been  lacera- 
tion and  consequently  are  of  considerable  medico-legal  importance  in  certain 
cases,  because  furnishing  strong  evidence  for  or  against  a  previous  childbirth. 
The  color  of  the  edges  show  whether  they  are  normal  or  the  seat  of  inflammation 
or  erosion. 

The  discharge  may  be  of  any  of  the  varieties  previously  described.  There 
is  normally  a  clear  sticky  tenacious  mucus  in  the  cer\dx  and  about  the  external 
OS.  The  first  effect  of  inflammation  and  irritation  is  to  make  this  more  abundant 
and  later  it  becomes  mixed  v-ith  pus.  As  long  as  the  cervical  inflammation  is  a 
prominent  part  of  the  process,  the  tenacious,  string}^  quality  ^^ill  be  a  prominent 
feature  of  the  discharge.  If  there  is  the  least  suspicion  of  gonorrhoea,  make  a 
spread  of  the  discharge  for  microscopic  examination.  Occasionally  a  small  polypus 
will  be  seen  presenting  at  the  external  os  or  hanging  by  a  pedicle. 

Difficulties  in  the  Speculum  Examination. 

Poor  Light.  If  the  light  is  so  poor  that  the  cervix  and  upper  portion  of  the 
vagina  cannot  be  seen,  the  ordinary  head  mirror,  used  in  throat  work,  is  of  much 
assistance.  At  night,  in  emergency  examinations  and  treatment,  the  light  from 
a  lamp  may,  with  the  head  mirror,  be  thrown  into  the  vagina  and  the  landmarks 
easily  seen. 

Painful  abrasions.  If  there  are  painful  abrasions  or  fissures  about  the  vaginal 
orifice  which  interfere  with  the  examination,  the  sensitiveness  may  be  diminished 


THE  SIMS  SPECULUM  §3 

by  the  applifatioii  of  a  small  piece  i)(  ahsorbeiit  cotton  soaked  in  a  10%  cocaine 
solution.  Leave  this  in  place  for  three  to  five  minutes,  then  remove  it  and  proceed 
with  the  examination. 

Redundant  Vaginal  Walls.  When  the  va.iiinal  walls  are  ver}-  lax  and  redundant, 
as  sometimes  occurs  because  of  subimolution  following  labor,  they  collapse  about 
the  speculum  in  such  a  way  as  to  hitle  the  cervix.  This  difficulty  may  in  some 
cases  be  overcome  by  using  a  longer  speculum.  When  this  does  not  expose  the 
cervix  satisfactorily,  put  the  patient  in  Sims'  posture  and  use  the  Sims  speculum. 

Examination  with  Cylindrical  Speculum. 

The  cylindrical  speculum  consists  simply  of  a  tube  with  the  outer  end  flaring 
and  the  inner  end  cut  obhquely.  It  may  be  made  of  metal  or  hard  rubber  or  glass. 
The  cylindrical  speculum  is  useful  in  certain  foims  of  treatment,  particularly  when 
it  is  desired  to  apply  to  the  cervix  medicines  from  which  the  vaginal  walls  should 
be  protected,  but  it  is  not  much  used  in  examination  work. 

When  in  the  examination  of  a  girl  it  is  necessary  to  inspect  the  cervix,  this  may 
be  accomplished  T\ithout  disturbing  the  hymen  by  placing  thepatientin  the  knee- 
chest  posture  and  using  one  of  Kelly's  cystoscopic  tubes.  This  is  simply  a  small 
cylindrical  speculum  and,  with  the  patient  in  the  knee-chest  posture,  when  the  tube 
is  introduced  the  vagina  balloons  out  to  some  extent  with  air.  Then  by  means  of 
a  light  reflected  from  a  head-mirror,  the  cervix  and  vaginal  walls  may  be  inspected 
and  if  necessary  treated.  Such  an  examination,  however,  is  seldom  required. 
In  the  virgin,  a  local  examination  should  not  be  made  except  for  urgent  symptoms, 
and  in  cases  with  urgent  symptoms  the  requirement  is  usually  for  a  thorough  bi- 
manual examination  under  anesthesia,  rather  than  for  a  speculum  examination. 

Examination  with  the  Sims  Speculum. 

The  Sims  speculum  is  a  perineal  retractor  and  for  use  requires  the  patient  to 
be  put  in  the  Sims  posture.  Like  any  other  retractor,  it  must  be  held  in  place 
either  by  an  assistant  or  by  a  mechanism  (.speculum  holder),  of  which  there  are 
several  varieties. 

The  Sims  speculum  consists  of  a  blade,  somewhat  resembling  a  duck's  bill,  and 
a  handle.  As  usually  made  tw'o  blades  are  placed  on  one  handle,  a  large  blade  at 
one  end  and  a  small  blade  at  the  other.  A  further  improvement  is  a  flange  near 
the  larger  blade.  This  flange  holds  the  fleshy  part  of  the  right  buttock  up  out  of 
the  w^ay.  The  Graves  bivalve  speculum,  mentioned  above,  is  easily  and  quickly 
changed  into  a  satisfactory  Sims  speculum  (Fig.  95),  so  it  is  not  usually  necessary 
to  get  a  special  Sims  speculum. 

Sims'  Posture.  The  principal  points  about  the  Sims  posture,  called  also  "left 
lateral  posture"  and  the  "semi-prone  posture,"  are  as  follows: 

1.  All  constriction  must  be  removed  from  around  the  waist. 

2.  The  patient  lies  on  her  left  side,  with  left  arm  and  hand  behind  her  and  the 
front  of  the  chest  turned  toward  the  table  as  far  as  possible  without  discomfort. 
When  in  proper  position,  the  upper  part  of  the  body  rests  on  the  left  breast. 


84 


THE  PHYSICAL  EXAMINATION 


3.  The  hips  rest  near  the  lower  left  corner  of  the  table  and  the  body  extends 
diagonally  across  the  table  toward  the  right  side. 

4.  The  left  thigh  is  drawn  up  so  that  it  forms  an  acute  angle  with  the  body, 
and  the  right  thigh  is  dra\\Ti  up  still  more,  and  allowed  to  drop  over  the  lower  one. 
This  puts  the  patient  in  the  position  shown  in  Figs.  96  and  97.  It  permits  the 
abnominal  wall  and  the  intestines  and  uterus  to  fall  forward. 

Use  of  Sims'  Speculum.  To  introduce  the  speculum,  the  right  labia  are  raised 
thus  exposing  the  vaginal  opening  and  then  the  speculum  point,  well  lubricated, 
is  carefully  worked  into  the  opening.  At  the  same  time,  the  perineum  is  pulled 
somewhat  backward  ^^ith  the  speculum  point,  in  order  to  give  more  room  for  the 

point  to  slip  in  (Fig.  98).  The  blade  is 
then  carried  all  the  way  in.  The  spec- 
ulum is  then  grasped  firmly  and  pulled 
backward,  thus  retracting  the  perine- 
um and  exposing  the  interior  of  the 
vagina  (Fig.  99). 

As  the  speculum  is  introduced  the 
vagina  becomes  distended  with  air,  and 
when  the  perineum  is  retracted  the 
cervix  and  anterior  vaginal  wall  may 
be  seen.  To  bring  the  cervix  into  still 
better  view,  catch  it  with  the  tenac- 
ulum-forceps  and  bring  it  shghtly  to- 
ward the  opening  (Fig.  100). 

When  indicated.  The  Sims  specu- 
lum vAih  the  Sims,  posture  is  of  de- 
cided advantage  in  the  following  con- 
ditions : 

1.  When  the  bivalve  speculum  fails 
to  satisfactorily  expose  the  cervix. 
This  may  be  due  to  the  vaginal  walls 
being  so  lax  that  they  fall  about  the  blades  and  obscure  the  cervix  or  it  may  be 
due  to  the  vaginal  opening  being  so  small  that  the  blades  cannot  be  sufficiently 
separated.  Again,  in  some  cases  of  inflammation  of  the  uterus  or  about  the 
uterus,  the  bivalve  speculum  cannot  be  opened  sufficiently  because  the  anterior 
blade  causes  pain  by  pressure  on  the  inflamed  structures. 

2.  When  it  is  desired  to  expose  a  lacerated  cervix  without  spreading  the  lips 
apart.  The  bivalve  speculum,  as  it  is  opened,  separates  the  lips  of  the  lacerated 
cervix,  causing  considerable  distortion  and  making  it  rather  hard  to  judge  of  the 
amount  of  e version  ordinarily  present.  Again,  the  weight  of  the  uterus  pushes 
the  cervix  into  the  vagina,  in  some  cases  making  the  cervix  appear  longer  than  it 
really  is.  In  this  way  the  bivalve  speculum  may  lead  to  an  erroneous  diagnosis 
of  elongation  of  the  cervix. 

3.  When  it  is  desired  to  expose  the  cervix  ^vith  the  least  possible  stretching  of 
the  vaginal  opening.  The  vaginal  opening  may  be  so  tender  that  the  bivalve 
speculum  cannot  be  satisfactorily  opened.     Again,  in  removing  cervical  sutures 


Bivalve  speculum  changed  to  Sims'  spe- 


THE  SIMS  POSTURE 


85 


after  simultaneous  repair  of  both  cervix  arul  perineum,  it  is  important  to  avoid 
stretching  the  newly  healed  perineum.  In  these  cases,  a  narrow  Sims  speculum 
introduced  in  the  Sims  posture,  causes  the  vagina  to  balloon  and  exposes  the  cervix 
and  vaginal  vault  with  much  less  stretching  of  the  vaginal  orifice  than  would  be 
necessary  with  the  bivalve  speculum. 

4.  When  it  is  desired  to  sound  the  uterus  or  to  dilate  the  cervical  canal  or  to 
make  an  intrauterine  application. 


Fig.  96.     Patient  in  Sims'  posture.     Notice  how  the  upper  knee  drops     |^// 
over  the  under  one.  ■' 


5.  When  the  vagina  is  to  be  packed,  either  for 
holding  the  uterus  forward  or  for  hemorrhage. 

6.  In  clearing  out  the  uterus  with  the  curet  for 
incomplete  miscarriage.  In  many  such  cases  where 
the  miscarriage  has  just  taken  place,  if  the  patient 
be  placed  in  the  Sims  posture  and  all  the  manipula- 
tions made  carefully,  the  uterus  may  be  thoroughly 
cleared  out  with  but  httle  pain  and  hence  without  an 
anesthetic. 


Fig.  97.     View 
the  arm   behind 
son  —  American 
fiCS.) 


e,  showing 

(Dickin- 

nf  Obttet- 


86 


THE  PHYSICAL  EXAMINATION 


7.  When  treating  a  sinus  or  abscess  opening  in  the  posterior  vaginal  fornix. 
When  making  the  incision  back  of  the  cervix  for  pelvic  abscess,  the  dorsal  posture 
is  the  better  one,  as  the  cervix  may  be  held  out  of  the  way  by  strong  traction, 
but  in  the  after-care  of  the  case,  the  Sims  posture  is  usually  preferable.  It  causes 
the  patient  less  pain  and  gives  much  better  exposure  of  the  opening  back  of  the 
cervix. 


Fig.  98.     Introducing  the  Sims  speculum. 


Fig.  99.  Speculum  in  place,  and  showing  also  the 
method  of  holding  the  same  and  of  keeping  the  upper 
buttock  out  of  the  way. 


EXCISION  OF  TISSUE 


FROM   CERVIX  FOR  MICROSCOPIC  EXAMINATION. 

In  many  cases  the  naked-eye  examination  of  the  cervix  is  not  sufficient  to  make 
a  positive  diagnosis  between  malignant  disease  and  certain  other  affections  of  the 
cervix.  In  a  suspicious  case,  particularly  one  that  resists  treatment,  a  small  piece 
of  the  affected  area  should  be  excised  for  microscopic  examination.  A  very  con- 
venient instrument  for  this  purpose  is  the  specimen  scissors  shown  in  Fig.  90. 
With  this  a  small  piece  of  the  su.spicious  tissue  may  be  chpt  out  of  the  cervix. 
If  there  is  much  bleeding,  a  suture  may  be  placed  under  the  bleeding  surface  and 
tied.  Usually  however  a  styptic  application,  with  a  firm  vaginal  packing,  will  stop 
the  bleeding.  The  specimen  excised  from  the  cervix  and  also  all  curettings 
should  at  once  be  placed  in  a  small  bottle  of  alcohol  (95%)  or  formol  (10%)  imd 
forwarded  to  the  pathologist. 


THE  UTERINE  SOUND 


87 


EXPLORATION  OF  UTERUS  WITH  SOUND. 

Through  the  speculum  the  interior  of  the  uterus  may  be  explored  with  the  uterine 
sound.  The  uterine  sound  (Fig.  101-a)  is  pliable  so  that  it  ma}^  be  bent  to  accom- 
modate it  to  the  uterine  canal  in  different  cases.  It  is  graduated  so  that  the  exact 
depth  of  the  canal  may  be  told.  It  has  a  bulbous  end  so  that  there  will  ]m  les.s 
danger  of  its  puncturing  the  uterine  wall. 


Fig.  100.     Cervix  caught  with  tenaculum-forceps  and  brought  into  view. 


Introduction  of  Uterine  Sound. 

The  sound  should  not  be  introduced  by  touch,  as  was  formerly  the  custom  and  as 

is  shown  even  in  some  recent  text-lxx)ks,  for  when  used  in  that  way  is  is  very  liable 
to  carry  infection  into  the  uterus.  Before  sounding,  the  speculum  should  be  intro- 
duced, the  cervix  exposed  and  caught  with  a  tenaculum-forceps  and  the  cervix 
and  vicinity  cleansed  with  a  reliable  antiseptic  solution.  Then  the  sterile  sound 
is  introduced  into  the  uterus  without' Toaching  the  vaginal  wall.  Before  intro- 
ducing the  sound  the  approximate  location  of  the  fundus  uteri  should  be  deter- 
mined by  bimanual  examination  and  the  sound  should  be  shaped  and  guided 


88  THE  PHYSICAL  EXAMINATION 

accordingly.  The  sound  can  usually  be  most  conveniently  introduced  with  the 
patient  in  the  Sims  posture  and  the  cervix  exposed  with  the  Sims  speculum. 
After  the  sound  is  sterilized  do  not  touch  the  intrauterine  portion  with  the  lingers. 
If  the  end  requires  bending,  dip  a  piece  of  absorbent  cotton  in  a  reliable  antiseptic 
solution  and  grasp  the  uterine  portion  of  the  sound  with  this  for  bending.  No 
force  should  be  used  in  the  introduction  of  the  sound,  other  than  is  necessary  to 
overcome  a  very  slight  stenosis.  If  the  sound  does  not  pass  easily  in  the  supposed 
direction  of  the  canal,  withdraw  it  slightly  and  try  in  other  directions.  If  it  does 
not  then  pass  easily  or  if  it  causes  much  pain  it  should  not  be  used  further. 


Fig.  101.  Instruments  for  exploring  the  interior  of  the  uterus,  a.  Uterine  sound,  b.  Three  graduated 
metal  dilators  for  enlarging  the  cervical  canal,  c.  Small  branched  dilator,  d.  Small  exploring  curet. 
e.  Intra-uterine  applicator. 

Information  Obtained  by  Uterine  Sounding. 

As  mentioned  later,  the  introduction  of  tiie  uterine  sound  is  dangerous  and 
rarely  necessary.  When  it  is  necessary  to  use  it,  the  information  obtained  should 
cover  the  following  points: 

Size  and  Shape  of  Cervical  Canal.  Is  thci-e  stenosis?  If  so,  is  it  located  at  llu' 
external  os  or  the  internal  os  or  between  the  two?  Is  there  anteflexion  of  cer.vix? 
This  is  indicated  Ijy  a  sharp  bend  forward  of  thg  canal  at  the  internal  os.     In  slich 


THE  USE  OF  THE  SOUND  gg 

a  case,  even  when  there  is  no  obstruction,  the  sound  often  stops  at  this  point 
because  it  impinges  on  the  posterior  wall  of  the  canal,  and  if  force  were  used  the 
wall  would  be  injured.  Curve  the  sound  sharply  so  as  to  throw  the  point  forward 
in  a  direction  to  pass  the  bend. 

Position  of  Body  of  L'terus.  Does  the  point  of  the  sound  pass  in  the  direction 
normally  occupied  by  the  uterine  canal  or  is  the  canal,  and  consequently  the  body 
of  the  uterus,  displaced?  If  so,  is  the  displacement  backward  or  forward  or  lateral? 
The  direction  of  the  canal  helps  also  in  determining  which  of  two  masses  in  the 
pelvis  is  the  uterus,  in  cases  in  which  this  cannot  be  otherwise  determined. 

Length  of  Uterine  Cavity.  Is  there  enlargement  of  the  uterus?  If  so,  to  what 
extent?  In  chronic  inflammation  and  in  subinvolution  there  is  slight  enlarge- 
ment. In  tumors,  particularly  in  large  intramural  filjroids,  there  may  be  great 
elongation  and   distortion   of  the  canal. 

Pain.  There  is  usually  some  pain  as  the  sound  passes  the  internal  os.  In  cer- 
tain cases  of  inflammation  and  of  neuralgic  trouble,  the  pain  is  much  increased 
and  the  excessive  tenderness  may  extend  to  the  entire  endometrium. 

Bleeding.  A  drop  or  two  of  blood  may  follow  sounding  when  the  uterus  is  nor- 
mal, but  many  drops  or  a  slight  stream  following  careful  sounding,  indicates  a 
pathological  condition  of  the  endometrium. 

Centra-indications  to  Uterine  Sound. 

There  is  considerable  danger  in  the  use  of  the  sound,  even  when  handled  with 
care.  It  may  carry  infection  into  the  uterus  or  it  may,  by  the  irritation,  stir  to 
activity  a  chronic  inflammation  or  it  may  injure  the  wall  of  the  canal  or  it  may 
perforate  the  uterus  and  enter  the  peritoneal  cavity.  The  danger  of  j^erforation 
is  especially  marked  in  a  uterus  recently  pregnant  or  the  seat  of  malignant  disease. 
When  proficiency  in  the  bimanual  examination  is  acquired,  the  introduction  of 
the  uterine  sound  will  seldom  be  necessary. 

Remember  the  following  rules  as  to  sounding  the  uterus: 

Do  not  sound  unless  their  is  some  special  reason  for  it. 

Do  not  sound  when  there  is  active  inflammation  in  the  vagina  or  cervix 

with  the  body  of  the  uterus  free  or  when  there  is  an  acute  or  subacute 

salpingitis. 
Do  not  sound  when  there  is  a  suspicion  of  pregnancy. 

If  not  extremely  careful,  you  are  liable  in  some  doubtful  case  to  inadvertently 
sound  a  pregnant  uterus  and  cause  serious  trouble  for  the  patient  and  for  yourself. 
To  avoid  this,  it  is  a  good  plan  always,  just  before  introducing  the  sound,  to  ask  the 
patient,  ''When  did  you  menstruate  last?"  and  to  ask  yourself,  "Is  there  any  sus- 
picion of  pregnancy  in  this  case?"  If  there  is  suspicion  of  pregnancy,  put  the 
patient  on  some  treatment  that  cannot  interfere  with  pregnancy  and  watch  the- 
case  until  the  next  menstrual  period.  If  you  doubt  the  patient's  statement  that 
she  is  menstruating  regularly,  tell  her  that  you  must  see  her  when  menstruating 
the  next  time,  that  you  may  determine  the  nature  of  the  flow.  In  that  way  you 
can  determine  whether  or  not  she  really  menstruates. 


90  THE  PHYSICAL  EXAMINATION 


EXPLORATION  OF  UTERUS  WITH  CURET. 

The  exploration  of  the  interior  of  the  uterus  with  the  curet,  without  anesthesia, 
is  for  the  purpose  of  removing  pieces  of  tissue  for  microscopic  examination. 
Usually  curetment  imder  anesthesia  is  preferable.  In  some  cases,  however,  there 
are  contra-inclications  to  anesthesia  or  for  some  other  reason  it  is  thought  best 
to  try  to  secure  some  tissue  for  microscopic  examination  so  that  a  diagnosis  may 
if  possible  be  made  before  giving  an  anesthetic. 

The  curet  used  for  such  exploration  should  be  small  and  should  have  a  sharp 
cutting  edge  (Fig.  101-d). 

Method  of  Procedure. 

The  preparations  are  the  same  as  for  sounding  the  uterus — in  fact,  exploration 
with  the  sound  should  immediately  precede  exploration  vnth.  the  curet.  The  slight 
dilatation  required  and  the  subsequent  exploration  with  the  curet,  are  usually 
best  carried  out  ^^'ith  the  patient  in  Sims'  posture. 

In  some  cases  the  cervix  ^nll  readily  admit  this  small  curet  without  dilatation. 
Usually,  however,  some  dilatation  is  necessary  and  this  is  most  easily  effected 
with  the  graduated  dilators  (Fig.  101-b)  of  metal  or  hard  rubber.  Beginning  "^ith 
the  small  size,  the  dilators  are  introduced  one  after  another  until  the  required 
dilatation  is  secured.  The  cervix  is  caught  and  steadied  with  a  tenaculum-forceps, 
while  dilatation  is  being  made.  As  a  substitute  for  uterine  dilators,  the  ordinary 
steel  bougies  for  the  male  uretha  do  very  well  in  most  cases.  If  preferred,  the 
dilatation  may  be  effected  with  a  small  bladed  dilator  (Fig.  101-c)  or  a  curved 
uterine  dressing-forceps.  The  bladed  instrument  is  introduced  closed  and  then 
gradually  opened  sufficiently  to  give  the  required  dilatation.  This  is  more  painful 
usually  and  less  convenient  than  the  graduated  dilators.  All  the  manipulations 
should  be  made  genth^,  and  nothing  more  than  sHght  dilatation  should  be  attempted, 
as  it  would  cause  too  much  pain.  This  dilatation  without  anesthesia  is  not  prac- 
ticable in  the  virgin,  ordinarily,  though  in  some  cases  it  can  be  carried  out  very 
well. 

A  method  of  securing  a  wider  opening  by  slow  dilatation  is  by  packing  the  cervi- 
cal canal  with  antiseptic  gauze.  If  carried  out  carefully  this  is  safe,  and  is  some- 
times effective.  Under  the  same  antiseptic  preparation  as  for  the  other  methods 
of  dilatation,  a  thin  strip  of  gauze  is  introduced  into  the  uterus,  past  the  internal 
OS  if  possible,  and  the  cervical  canal  is  packed  firmly  with  it,  the  end  being  left  out 
of  the  cervix.  This  is  held  in  place  by  a  vaginal  packing  of  the  same  material. 
The  patient  should  go  to  bed  as  soon  as  she  reaches  home  and  remain  there  until 
the  time  for  the  next  treatment.  In  twentj^-four  hours  the  packing  is  removed 
and  the  cervical  canal  is  found  considerably  softened  and  dilated. 

Formerly  tents  were  much  used  for  dilating  the  cervix.  Such  a  tent  was  simply 
a  dry  cone  of  some  substance  which,  when  moist,  gradually  expanded  with  suffi- 
cient force  to  dilate  the  cervix.  The  dilatation  required  several  hours  and 
sometimes  several  days,  the  patient  in  the  meantime  being  given  morphine  on 
account  of  the  pain.     The  substances  used  were  sponge,  laminai'ia   and   tupelo. 


EXAMINATION  UNDER  ANESTHESIA  91 

Many  deaths  were  caused  by  infection  resultino;  from  the  use  of  tents,  and  even 
in  skihed  hands  and  with  all  the  modern  antiseptic  precautions,  tents  still  cause 
serious  tvouVile  at  times.  Consequently  their  use  has  been  almost  abandoned. 
If  used  at  all,  the  tent  should  be  covered  with  a  sterilized  rubber  tent  cover. 

After  the  reciuired  dilatation  has  been  secured,  the  curet  is  introduced  and  por- 
tions of  the  diseased  endometrium  removed  for  microscopic  examination.  If 
there  is  persistent  bleedinij;  after  the  use  of  the  curet,  an  intrauterine  application 
of  a  10  per  cent  copper  sulphate  solution  may  be  used.  If  the  bleeding  still  per- 
sists, a  small  piece  of  antiseptic  gauze  should  be  packed  firmly  into  the  uterine 
cavity  and  the  vagina  also  packed  with  gauze.  The  gauze  may  be  removed  in 
t  wo  days  and  an  antiseptic  vaginal  douche  given  once  or  twice  daily  for  a  few  days. 

Contra=indications.  The  use  of  the  curet  for  diagnosis  is  contra-indicated  by 
tlie  same  conditions  that  contra-indicate  the  sound.  The  use  of  the  curet  with- 
out anesthesia,  as  just  described,  is  not  nearly  as  satisfactory  as  the  regular  curet/- 
ment  under  anesthesia. 


PELVIC  EXAMINATION  UNDER  ANESTHESIA. 

The  advantage  of  anesthesia  is  that  it  eliminates  pain  and  Must:uLAR  tension, 
the  two  factors  that  make  the  ordinary  pelvic  examination  incomplete  and  un- 
satisfactory in  certain  cases. 

Preparations. 

In  preparation  for  this  examination  the  patient's  bowels  should  be  moved  with 
a  purgative  on  the  previous  day  and  the  rectum  should  be  cleared  out  with  an 
enema  an  hour  or  two  before  the  examination.  The  same  preparatory  examina- 
tion of  the  heart,  lungs  and  urine  should  be  made  as  though  the  anesthesia  Ave  re  for 
an  operation.  Have  ready  a  light  strong  tenaculum-forceps,  so  that  the  cervix 
may  be  caught  and  the  uterus  pulled  down  as  desired.  If  the  interior  of  the  uterus 
is  to  be  explored,  the  antiseptic  preparation  for  curetment  must  be  carried  out. 

Examination  Methods. 

The  various  manipulations  employed  in  examination  under  anesthesia  are  as 
follows : 

Vagino-abdominal  palpation, 

Recto-abdominal  palpation, 

Recto-vagino-abdominal  palpation, 

Recto-vesical  palpation, 

Curetment, 

Exploration  of  interior  of  uterus  with  finger, 

Excision  of  i^iece  of  cervix  for  examination. 

VAGINO-ABDOMINAL  PALPATION. 

In  vagino-abdominal  palpation  under  anesthesia,  the  same  manipulations  are 
employed  and  the  same  facts  concerning  normal  and  almormal  pelvic  structures 


92  THE  PHYSICAL  EXAMINATION 

are  sought,  as  in  the  ordinary  vagino-abdominal  (bimanual)  examination.  Under 
anesthesia,  however,  the  examination  is  much  more  thorough.  Deep  palpation 
may  be  made  in  all  portions  of  the  pelvis,  and  the  uterus,  tubes,  ovaries  and  ab- 
normal masses  may  be  clearly  outlined  in  nearly  every  case.  The  position,  size, 
shape,  consistency,  mobility  and  attachments  of  a  pelvic  mass  may  be  determined 
with  far  more  accuracy  than  without  anesthesia. 

In  all  doubtful  cases,  this  method  of  examination  should  be  employed  before 
subjecting  the  patient  to  abdominal  section. 

In  the  examination  under  anesthesia,  the  manipulations  must  always  be  made 
carefully  and  gently,  otherwise  a  collection  of  pus  may  be  broken  open  internally, 
causing  peritonitis,  or  the  sac  of  a  tubal  pregnancy  may  be  ruptured,  causing  fatal 
hemorrhage. 

RECTO-ABDOMINAL  PALPATION. 

The  recto-abdominal  palpation  under  anesthesia  is  made  for  the  same  purpose 
as  the  vagino-abdominal  palpation  and  in  the  same  way  except  that  two  fingers 
of  the  gloved  hand  are  introduced  into  the  rectum  instead  of  into  the  vagina. 

Much  additional  information  may  be  in  this  way  obtained  in  some  cases  because, 
under  anesthesia,  the  fingers  can  pass  further  up  the  posterior  surface  of  the  uterus. 
By  catching  the  cervix  with  a  tenaculum-forceps  and  pulling  the  uterus  downward, 
the  posterior  surface  of  the  uterus  and  the  ovaries  and  the  broad  ligaments  may  be 
palpated  with  but  little  intervening  tissue. 

To  get  the  full  benefit  from  this  method,  particular  attention  must  be  paid  to 
details.  After  the  patient  is  well  under  the  anesthetic  and  as  much  information 
as  possible  has  been  secured  by  vagino-abdominal  palpation,  then  make  the  recto- 
abdominal  examination  as  follows: 

1.  Cleanse  the  rubber  glove  from  all  vaginal  secretion  or  put  on  a  fresh  one 
(that  no  infection  be  carried  into  the  rectum),  and  lubricate  the  glove  with  a  drop 
or  two  of  liquid  soap.  If  the  bare  fingers  have  been  used  for  vaginal  examination, 
cleanse  them  and  put  on  a  rubber  glove.  If  no  rubber  glove  is  at  hand,  fill  the 
opace  under  the  nails  of  the  examining  fingers  by  scraping  across  a  bar  of  soap 
and  then  lubricate  the  fingers  with  a  drop  or  two  of  liquid  soap  or  with  an  abun- 
dance of  vaseline  or  other  bland  ointment.  If  no  rubber  glove  is  worn,  the  exam- 
ining fingers  should,  immediately  after  the  examination,  be  dipped  at  once  (before 
putting  them  in  soap  "and  water)  into  a  strong  antiseptic  solution  (e.  g.,  bichloride 
1-1000)  and  scrubbed  in  that  with  a  piece  of  cotton.  After  that  they  are  put  through 
the  regular  scrubbing  with  soap  and  water  and  a  brush.  This  immediate  cleansing 
in  a  strong  antiseptic  solution  before  the  regular  scrubbing  with  soap  and  water, 
aids  in  removing  the  odor. 

2.  Introduce  two  fingers  into  the  rectum.  Under  the  anesthetic,  the  sphincter 
ani  is  readily  dilated  to  admit  the  two  fingers  as  they  are  carefully  worked  in. 
A  much  more  thorough  recto-abdominal  palpation  of  the  pelvic  interior  may  be 
made  with  two  fingers  in  the  rectum  than  with  only  one. 

The  fingers  are  worked  past  the  rectal  folds,  up  between  the  sacro-uterine  liga- 
ments, which  serve  as  landmarks,  and  then  as  far  up  beyond  as  possible.  The 
anus  and  pelvic  floor  are  pushed  into  the  pelvis  as  far  as  they  will  go,  by  firm.pres- 


RECTO-ABDOMINAL   PALPATION 


93 


sure  against  the  elbow  of  the  examining  arm,  the  elbow  resting  on  the  knee  or 
against  the  hip,  as  in  deep  vagino-abdominal  palpation.  In  this  way  the  tips  of 
the  examining  fingers  may  be  carried  far  up  into  the  posterior  part  of  the  pelvis. 
There  may  be  some  difficulty  in  finding  the  rectal  canal  in  the  region  of  the 
sacro-uterine  ligaments.  Sometimes  the  interior  of  the  rectum  feels  like  a  large 
pouch  without  any  opening  extending  higher.  If  you  are  satisfied  to  make  the 
pelvic  palpation  by  attempting  to  carry  up  the  wall  of  this  pouch,  you  will  be  much 
hampered.  By  locating  the  cervix  uteri  and  then  the  two  sacro-uterine  ligaments 
and  working  round  to  get  past  the  rectal  valves  and  folds,  a  small  opening  will  be 
felt  extending  upward  between  the  sacro-uterine  ligaments.  Follow  this  up  (it 
dilates  easily)  and  you  will  find  further  progress  unobstructed.  The  fingers  are 
carried  as  high  as  they  will  go  and  then  the  al^dominal  wall  is  depressed  from  above 
by  the  other  hand  (Fig.  102). 

3.  The  various  structures  in  the  posterior  and  central  parts  of  the  pelvis  are  then 
caught  between  the  hands  and  outlined  and  otherwise  examined  ])v  palpation, 
one  at  a  time.     The  palpation  proper  is 

made  principally  with  the  rectal  fingers, 
the  abdominal  fingers  serving  simply  to 
push  down  the  structures  to  within  reach 
of  the  fingers  below.  In  this  palpation, 
the  guide  is  the  body  of  the  uterus.  The 
fingers  pass  up  the  posterior  surface  of  the 
uterus  to  the  fundus  and  then  out  to  the 
lateral  region  of  each  side,  palpating  the 
tube  and  ovary  and  any  abnormal  mass. 
In  a  patient  with  only  a  moderately  thick 
abdominal  wall,  the  ovaries  and  tubes 
may  be  distinctly  outlined,  unless  they  are 
obscured  by  adhesions  or  by  an  inflam- 
matory mass  or  by  a  tumor. 

4.  Then  catch  the  cervix  with  a  tenaculum-forceps  and  draw  it  down  gently,  and 
have  someone  hold  the  forceps  to  keep  the  uterus  in  the  do\\Tiward  position.  This 
drawing  downward  and  forward  of  the  cervix,  throws  the  fundus  backward  so  that 
it  is  caught  between  the  rectal  fingers  and  the  abdominal  fingers;  and  its  size, 
shape,  consistency,  mobility  and  attachments  may  all  be  accurately  made  out. 

The  fingers  then  pass  to  the  adnexa,  determining  the  same  points  concerning 
them. 

If  there  is  a  movable  mass  of  doubtful  origin,  have  some  one  catch  it  from  the 
abdominal  surface  and  pull  it  up  towards  the  abdominal  cavity  so  that  the  ex- 
amining fingers  (rectal  and  abdominal)  may  meet  between  the  mass  and  the  pelvic 
structures.  In  this  way,  the  pedicle  of  the  mass  (if  it  ari-ses  from  the  pelvis)  may 
be  felt  and  traced  to  its  origin,  and  also  its  length  and  thickness  determined  (Fig. 
103).  This  is  sometimes  referred  to  as  Hegar's  method  of  examining  the  pedicle 
of  a  tumor. 

5.  Cautions.     Particular  care  must  be  exercised  that  the  structures  be  not  in- 


Fig.  102.  Recto-abdominal  palpation.  The  hand 
should  be  gloved.  (Montgomery  —  Proc^'ca/ 
gynecology.) 


94 


THE   PHYSICAL   EXAMINATION 


jiiriously  pressed  or  pulled  upon,  for  as  the  patient  is  anesthetized  the  usual  warn- 
ing complaint  of  pain  is  absent.  There  are  three  points  that  it  may  be  well  to 
mention  particularly: 

(a)  Do  not  use  much  force  in  palpation.  A  pus  sac  may  be  broken,  causing 
peritonitis,  or  a  tubal  pregnancy  may  be  disturbed  sufficiently  to  cause  a  fatal  hem- 
orrhage. In  fact,  a  patient  with  suspected  tubal  pregnancy  should  not  be  examined 
under  anesthesia  until  she  is  gotten  to  the  hospital  or  until  things  are  ready  in  the 
home,  so  abdominal  section  could  be  carried  out  immediately  should  threatening 
symptoms  arise  during  the  examination. 

Again,  if  much  force  is  used  the  examining  fingers  may  be  pushed  through  the 
I'ectal  wall  into  the  peritoneal  cavity.  Kelly  mentions  cases  in  which  this 
accident  occurred  and  in  which  immediate  abdominal  section,  or  vaginal  section, 
was  carried  out  to  repair  the  rent  in  the  bowel- wall  and  prevent  fatal  peritonitis. 

(b)  Do  not  draw  do"^Ti  the  uterus 
very  far  nor  very  forcibly,  for  reasons 
alread}'  given.  I  make  it  a  rule  to 
luring  the  uterus  dovrn  no  further  than 
is  absolutely  necessary  to  satisfactorily 
palpate  it.  In  most  of  these  cases  all 
that  is  necessary  is  a  slight  downward 
displacement,  that  permits  the  fundus 
to  go  somewhat  back-ward  so  that  it 
can  be  grasped  well  l^etween  the  rectal 
fingers  behind  and  the  al:>dominal  fin- 
gers in  front.  The  extreme  downward 
displacement  of  the  cervix,  to  the  vag- 
inal entrance  or  even  outside,  is  not 
necessary  nor  advisable,  except  in  cases 
where  there  is  already  prolapse  of  the 
uterus.  The  occasion  for  it  does  arise 
if  the  fingers  are  carried  up  the  rectum 
by  invagination  of  the  pelvic  floor,  as  above  described. 

(c)  The  suggestion  to  use  the  whole  hand  in  the  rectum  for  exploration  in  difficult 
cases,  was  long  ago  made  and  carried  out  with  disastrous  results.  This  method 
should  not  be  used.  It  has  led  to  rupture  of  the  rectum,  with  fatal  peritonitis. 
Furthermore,  no  need  for  it  is  experienced  if  the  palpation  with  two  fingers  is  carried 
out  vnth  close  attention  to  the  details  above  given. 


Fig.  103.  Palpatins  the  pedicle  of  a  tumor, 
with  the  tumor  pushed  up  into  the  abdominal 
cavity  and  the  uterus  caught  with  a  tenaculima- 
f creeps  and  pulled  downward.  (Montgomery — 
Practical  Gynecology.) 


RECTO-VAGINO-ABDOMINAL  PALPATION. 

In  some  cases,  additional  information  may  be  obtained  by  this  method.  With 
the  two  fingers  in  the  rectum,  the  thumi)  of  the  same  hand  is  passed  into  the  vagina 
and  the  lower  part  of  the  pelvic  mass  or  of  the  uterus  is  grasped  between  the  fingers 
and  the  thumb,  the  structures  being  pressed  down  within  reach  by  the  abdominal 
hand  (Fig.  104). 

In  some  cases,  this  is  of  decided  assistance  in  outlining  a  small  mass  low  in  the 


DlAGNOSriC  CURETMENT 


95 


pelvis  and  in  determining  the  exact  consistency  of  different  parts  of  it.  In  certain 
cases,  where  there  is  a  wide  vaginal  opening  and  relaxed  pelvic  floor,  the  examiner 
ma}'  palpate  the  uterus  or  other  mass  low  in  the  pelvis,  with  almost  as  much  accu- 
racy as  though  it  were  removed  and  lying  free  in  the  hand. 

A  modification  of  this  method  is  to  introduce  the  middle  finger  into  the  rectum  and 
the  index  finger  into  the  vagina  and  palpate  the  structures  between  the  fingers  as 
the  uterus  is  pushed  down  from  above.  This  method  of  recto-vagino-abdominal 
palpation  has  been  found  useful  in  determining  the  extent  of  involvment  of  the 
parametrium  in  cases  of  carcinoma  of  the  cervix  uteri. 


RECTO-VESICAL  PALPATION. 

In  the  recto-vesical  palpation  under  anesthesia,  a  medium  sized  urethral  bougie 
(about  21  F)  is  introduced  into  the  bladder,  and  one  or  two  fingers  into  the  rectum. 
The  tissues  between  the  rectum  and  the  end  of  the  bougie  are  carefully  palpated 
by  the  rectal  fingers.  This  method  is 
used  in  only  two  conditions — (a)  in 
determining  the  presence  or  absence  of 
the  uterus  in  cases  of  atresia  of  va- 
gina and  (b)  in  distinguishing  between 
inversion  of  the  uterus  and  a  large 
pedunculated  fibroid  hanging  from  the 
cervix.  In  a  very  stout  patient,  this 
method  may  be  the  only  means  of  mak- 
ing a  positive  diagnosis  in  the  classes 
of  cases  mentioned.  If  the  bladder  is 
not  irritable,  this  method  may  be  em- 
ployed gently  ^\'ithout  anesthesia,  but 
the  examination  under  anesthesia  is  far 
more  satisfactory. 

Caution.  Palpation  with  the  finger 
introduced  through  the  dilated  urethra, 
I  mention  only  to  condemn.  It  is  dang- 
erous in  that  it  is  liable  to  cause  per- 
manent incontinence  of  urine,  a  condi- 
tion which  resulted  in  several  reported 
cases. 


Fig.  104.  Recto-vagino-abdominal  palpation. 
One  or  two  fingers  of  tbe  gloved  hand  are  intro- 
duced into  the  rectum  and  the  thumb  into  the 
vagina,  and  the  uterus,  or  other  mass  low  in  the 
pelvis,  is  grasped  between  them,  as  it  is  pushed 
down  by  the  abdominal  hand.  (Montgomery — 
Practical  Gynecology.) 


CURETMENT  UNDER  ANESTHESIA. 

Curetment  for  diagnostic  purposes  is  carried  out  the  same  as  regular  curetment 
for  therapeutic  purposes.  By  it  tissue  is  obtained  from  all  portions  of  the  endo- 
metrium for  microscopic  examination.  As  previously  stated,  this  is  much  more 
satisfactory  than  the  partial  curetment  without  anesthesia,  for  by  the  curetment 
under  anesthesia  tissue  is  removed  from  practically  all  parts  of  the  cavity.  Conse- 
quently, if  in  the  subsequent  microscopic  examination  no  malignant  tissue  is  found, 
we  may  be  fairly  certain  that  there  is  no  malignant  disease.     Furthermore,  regular 


96  THE  PHYSICAL  EXAMINATION 

curetment  under  anesthesia  combines  with  its  diagnostic  vakie  a  decided  therapeutic 
effect,  for  it  removes  the  diseased  endometrium  and  diminishes  bleeding  and  dis- 
charge. As  will  appear  later,  curetment  is  often  indicated  in  a  particular  case  by  both 
therapeutic  and  diagnostic  considerations.  For  example,  when  a  patient  has  uterine 
bleeding  or  discharge  that  resists  ordinary  treatment,  curetment  is  indicated  to 
stop  the  bleeding  or  discharge  and  also  to  furnish  tissue  for  microscopic  examination. 
Of  the  various  conditions  that  give  rise  to  persistent  bleeding  and  discharge 
the  follomng  produce  characteristic  changes  in  the  endometrium: 

Chronic  endometritis, 
Malignant  disease  (carcinoma,  sarcoma), 
Tuberculosis  of  the  endometrium, 
Recent  abortion. 

There  are  other  conditions,  for  example,  extrauterine  pregnancy,  in  which  the 
microscopic  appearance  of  the  curettings  is  not  pathognomonic  but  in  wliich  the 
information  obtained  in  this  way,  added  to  the  symptoms,  may  make  the  diagnosis 
positive  in  an  otherwise  doubtful  case. 

Collecting  Curettings. 

In  a  diagnostic  curetment,  observe  the  following  points: 

1.  Remove  the  endometrium  from  all  parts  of  the  uterine  cavity. 

2.  Put  all  the  curettings  into  a  small  vessel  immediately  and  shake  with  water 
to  remove  blood-clots.  If  the  water  is  so  bloody  that  it  is  desired  to  change  it  for 
further  wasliing,  it  is  poured  through  gauze.  The  gauze  catches  the  curettings, 
which  are  then  emptied  into  fresh  water.  The  water  into  which  curettings  are 
placed  should  be  clear  and  clean.  Normal  saline  solution  is  preferable  to  plain 
water  as  it  causes  less  sweUing  of  the  cells,  hence  it  should  be  used  for  the  washing 
when  the  curettings  are  to  be  subjected  to  any  particular  or  special  examination. 

3.  Then  transfer  all  the  tissue  fragments,  without  compression,  to  the  small 
bottle  containing  95%  alcohol  or  10%  formol  solution  and  send  to  the  laboratory. 

4.  If  the  pathologist  is  in  a  distant  city,  the  little  bottle  should  be  corked  securely 
and  put  in  a  mailing  tube  or  wrapped  with  cotton  and  other'^dse  packed  securely 
for  safe  transmission. 

5.  With  the  specimen,  send  a  note  stating  the  nature  of  the  specimen  (curettings 
from  within  uterus),  when  obtained,  name  and  age  of  patient  and  some  of  the 
important  facts  in  the  history  of  the  case. 

EXPLORATION  OF  UTERINE  CAVITY  WITH  FINGER. 

Exploration  of  the  interior  of  the  uterus  with  the  finger  may  be  employed  when 
satisfactory  information  cannot  be  obtained  otherwdse.  The  cervix  may  be  di- 
lated in  the  same  manner  as  for  curetment,  i.  e.,  with  a  strong  bladed  dilator,  but 
the  dilatation  must  be  carried  much  further,  as  it  takes  a  larger  opening  to  admit 
the  finger  than  to  admit  the  caret.  The  dilatation  required  for  satisfactory  explo- 
ration with  the  finger  must  be  so  wide  that  it  is  only  in  exceptional  cases  that  it 
can  be  secured  in  the  non-puerperal  uterus  with  the  ordinary  dilator. 


DIGITAL  KXPLOUATIO.V  OV  UTERINK  CAVITY 


97 


To  secure  satisfactory  dilatation,  Schatz's  metranoikter  may  be  used.  This 
consists  of  two  blades  separated  by  a  strong  spring.  They  are  introduced  into  the 
cervix  closed.  The  removal  of  the  introducing  handle  releases  the  spring  which 
gradually  effects  wide  dilatation  of  the  cervix,  within  twelve  to  twent3^-four  hours. 
The  pain  is  controlled  by  morphine.  This  instrument  causes  wide  dilatation 
and  may  be  used  in  preparation  for  examination  under  anesthesia  where  for  some 
particular  reason  it  is  desired  to  palpate  the  interior  of  the  uterus.  It  may  be 
used  also  to  dilate  the  cervix  for  curetment  without  anesthesia  or  even  for  explora- 
tion of  uterus  with  the  finger  without  anesthesia. 

Hirst  has  modified  the  Schatz  metranoikter,  making  it  with  foui-  blades  instead 
of  two. 

A  more  certain  and  satisfactory  method,  when  the  patient  is  given  an  anesthetic, 
is  to  dilate  the  cervical  canal  to  the  usual  extent  with  the  regular  bladed  dilator 
and  then  divide  the  wall  of  the  cervix  with  a  knife  or  scissors,  in  the  median  line 
anteriorly  up  to  or  above  the  internal 
OS.     The  bladder  must  of  course  first 
be    separated    from     the   cervix   and 
pushed  up  out  of  the  way.  This  allows 
a  thorough  exploration  of  the  interior 
of  the  uterus  with  the  finger.     It  is  a 
rather   formidable  procedure   for   ex- 
ploration alone  and  usually  is  employed 
only  after  preparations  have  been  made 
to  do  a  hysterectomy  or  other  opera- 
tion immediately  after  the  exploration, 
if  such  is  found  necessary. 

After  sufficient  dilatation  has  been 
obtained  by  one  of  the  methods  men- 
tioned, the  finger  is  introduced  into 
the  uterine  cavity  and  the  walls  pal- 
pated, the  uterus  at  the  same  time  being  pushed  downward  and  steadied  by  the 
other  hand  the  same  as  in  bimanual  examination.  Some  additional  information 
may  be  obtained  by  this  method,  for  example,  we  may  determine  the  presence 
of  irregularities  of  the  uterine  wall,  of  projecting  growths,  of  softened  or  broken 
down  places  or  of  areas  of  induration. 

Exploration  of  the  uterine  cavity  with  the  finger  is  seldom  necessary  in  the  non- 
puerperal uterus.  In  all  but  exceptional  cases,  the  diagnosis  may  be  made 
without  it.  In  the  puerperal  uterus,  it  is  exceedingly  useful  for  determining  the 
presence  of  placental  remnants  (Fig.  105)  and  for  safely  clearing  out  the  same. 
InlTie  recently  pregnant  uterus  no  special  dilatation  measures  are  necessary  be- 
cause the  cervix  is  so  soft  that  abundant  dilatation  is  secured  with  the  ordinary 
bladed  dilator  or  in  some  eases  even  with  the  finger  alone. 


Fig.  105.  Exploration  of  the  interior  of  the  uterus 
with  the  finger.  This  represents  a  puerperal  uterus 
with  retained  placental  remnants.  (Edgar — Practice  of 
Obstetrics.) 


EXCISION  OF  TISSUE  FROM  CERVIX. 

Excision  of  a  piece  of  tissue  from  the  cervix  for  microscopic  examination  may 
be  quickly  carried  out  following  curetment  or  other  exploratory  examination, 


98 


THE  PHYSICAL  EXAMINATION 


\5^hen  thought  advisable.  In  this  way  a  positive  diagnosis  of  maUgnant  disease 
of  the  cervix  may  be  made  in  the  early  stage.  This  aid  to  diagnosis  should  be  car- 
ried out  during  the  examination  under  anesthesia  whenever  a  suspicious  ulcer  or 
induration  is  present.  A  small  wedge-shaped  portion  of  the  suspicious  area,  in- 
cluding some  healthy  tissue,  is  excised  and  the  wound  thus  made  is  closed  by 
one  or  two  sutures.  The  sutures  should  be  left  in  about  ten  days,  the  patient  in  the 
meantime  receiving  one  or  two  antiseptic  douches  daily.  She  need  not  remain  in  bed. 


Fig.  106,     Kitchen  table,  with  portable  foot-rests  attached  ready  for  a  gynecological  examinatioa. 


PREPARATIONS  FOR  GYNECOLOGICAL  EXAMINATION. 

The  various  points  considered  under  this  head  may  be  grouped  as  follows.- 
Office  Arrangements. 
Directions  to  Patient; 
Antiseptic  Preparations. 
Soap,  Brushes,  Lubricant. 
Use  of  Rubber  Gloves. 
Avoid  Unnecessary  Exposure. 
Preservation  of  Specimens. 
Examination  on  Bed.' 


PREPARATIONS  FOR  GYNECOLOGIC.VL  EXAMINATION  99 


OFFICE  ARRANCJEMENTS. 

There  are  three  thin.sis  of  particuhir  importance  in  the  liandliiiii;  of  f?ynecological 
patients: 

1.  Screened  Area  in  the  consulting  room.  The  portion  of  the  room  that  is  used 
for  the  examination  should  be  siiital)ly  screened  from  the  other  part,  so  that  the 
patient  may  remove  the  corset  and  make  such  other  arrangement  of  the  clothing 
as  she  wishes,  in  privacy.  It  is  very  convenient  to  have  a  separate  room  for  the 
examining- room,  with  an  attached  toilet-room.  Where  no  separate  room  is  avail- 
able, a  neat  substantial  screen,  affording  the  patient  privacy  for  the  required  prepa- 
ration, does  ver}'  well  and  is  inexpensive. 

2.  Table.  A  satisfactory  table  for  gynecological  examinations  is  the  regular 
surgical  chair  with  foot-rests.  The  advantage  of  the  foot-rests  is  that  the  pa- 
tient's hips  may  be  brought  to  the  end  of  the  table  without  her  feet  being  forced 
so  near  the  buttocks  as  to  be  uncomfortable. 

In  the  absence  of  the  surgical  chair,  portable  foot-rests  may  be  attached  to  a 
plain  kitchen  table  (Fig.  106;.  With  these  portable  foot-rests  are  furnished  also 
tall  uprights  for  use  as  leg-holders,  by  which  the  feet  and  legs  may  be  held  out  of 
the  way  during  examination  under  anesthesia  or  during  an  operation.  They  are 
convenient  for  use  during  minor  operations  at  the  patient's  home  (Fig.  572) . 

3.  Nurse.  When  a  physician  is  doing  much  gynecological  work  it  will  be  found 
a  wise  investment  to  have  a  nurse,  to  prepare  the  patients  for  examination  and 
to  prepare  the  necessary  articles  needed  in  office  examination  and  treatment. 
Aside  from  the  great  convenience  to  the  physician,  it  makes  the  patients  more 
at  ease  and  in  addition  tends  to  protect  the  physician  from  blackmail  by  designing 
persons.  Where  a  nurse  is  not  required  for  other  work,  she  may  be  hired  just  for 
the  office  hours  and  thus  the  expense  reduced. 


DIRECTIONS  TO  PATIENT. 

Direct  the  patient  to  remove  the  corset  and  loosen  all  bands  about  the  waist,  so 
that  the  clothing  may  be  pushed  up  and  down  sufficiently  to  bare  the  abdomen. 
This  is  necessary  at  first,  for  the  first  examination  should  be  thorough,  including 
examination  of  the  entire  abdomen  as  well  as  the  pelvic  exploration.  Examina- 
tion of  the  breasts  may  be  necessary  in  cases  of  suspected  pregnancy.  If  there 
are  indications  of  disease  of  the  heart  or  lungs,  those  organs  also  should  be  ex- 
amined, and  the  same  is  true  of  the  nervous  system. 

In  the  subsequent  visits,  it  may  not  be  necessary  to  remove  the  corset  or  loosen 
the  clothing,  depending  of  course  on  what  treatment  or  further  examination  is 
required.  It  is  not  necessary  in  ordinary  cervical  or  vaginal  treatments.  Any 
treatment  however  necessitating  deep  bimanual  palpation,  such  for  example  as 
replacement  of  a  retro-displaced  uterus,  requires  the  removal  of  the  corset  and 
loosening  of  bands. 

After  completing  the  abdominal  examination,  direct  that  the  hips  be  brought 
to  the  foot  of  the  table.     The  patient  is  covered  mth  a  clean  sheet  and  under  the 


100  THE  PHYSICAL  EXAMINATION 

sheet  the  skirts  are  pushed  up  above  the  knees  and  out  of  the  V7SLy.  The  sheet  is 
then  parted  so  as  to  expose  the  genitals  onty,  being  draped  so  as  to  cover  other 
parts.  It  is  well,  as  a  rule,  to  inspect  the  genitals,  for  often  information  of  value 
is  obtained  in  cases  where  the  history  gives  no  intimation  of  disturbance  externally. 
If  it  is  thought  unnecessary  to  inspect  the  genitals,  the  hand  is  carried  under  the 
sheet  for  making  the  vaginal  and  vagino-abdominal  examination. 

ANTISEPTIC  PREPARATIONS. 

If  you  wish  to  protect  your  patient  and  likewise  your  hands  from  the  danger 
of  infection,  certain  antiseptic  precautions  must  be  taken.  The  necessar}^  measures 
are  simple  and  easily  earned  out,  and  if  employed  regularly  become  more  or  less 
of  a  habit. 

The  needed  disinfection  T^ill  be  incUcated  by  naming  the  dangers  to  be  avoided, 
which  are  as  follows: 

1.  Infection  of  the  patient  from  your  hands.  If  your  hands  are  well  cleansed 
before  each  examination,  there  can  be  no  infection  from  them. 

2.  Infection  of  j^our  hands  from  the  patient.  If  there  is  a  scratch  or  abrasion 
anywhere  about  the  fingers,  the  hand  should  be  co\'ered  "uith  a  rubber  glove 
(Fig.  53).  If  no  rubber  glove  is  at  hand,  a  rubber  finger-cot  should  be  sHpped 
over  the  abraded  finger  or  the  abrasion  covered  with  collocUon  spread  over  a  few 
fibers  of  cotton.  If  the  collodion  rubs  off  during  the  examination  of  a  patient  "oith 
syphilis  or  chancroid  or  other  infectious  disease,  the  abrasion  must  be  immed- 
iately touched  with  pure  carbolic  acid  or  nitric  acid  and  again  covered  with  col- 
lodion. We  hear  a  gi'eat  deal  about  the  danger  of  the  patient  becoming  infected, 
but  very  little  about  the  danger  to  the  physician;  and  yet  I  suppose  there  are  few 
physicians  of  experience  who  do  not  number  among  their  professional  friends,  one 
or  more  who  have  become  infected  T^ith  syphilis  through  abrasions  of  the  hands. 
Dudley  states  that  he  is  acquainted  vdth  not  less  than  twenty  physicians  who  have 
been  infected  \^ith  s^-^Dhilis  through  abrasions  of  the  fingers  in  digital  examinations. 
Each  physician  must  look  out  for  himself  and  Ms  family.  Remember  that  "pre- 
vention is  better  than  cure,"  and,  it  may  be  added,  a  great  deal  easier. 

3.  Infection  of  the  patient  from  instruments.  If  the  instruments  are  sterilized 
each  time  before  use,  there  can  be  no  danger  from  them. 

4.  Infection  of  the  patient  from  the  table.  To  prevent  this,  place  under  the 
patient's  hips  a  rubber  pad  or  piece  of  rubber  cloth  and  over  that  a  clean  folded 
towel,  which  is  changed  ^xith  each  patient. 

Precautions.  The  precautions  to  be  taken  in  order  to  avoid  infection  may  be 
summed  up  in  three  rules,  as  follows: 

1.  Disinfect  and  Protect  the  Hands.  Trim  the  finger-nails  short  and  clean  under 
them.  Cleanse  the  hands  Avell  with  soap  and  water  and  dry  them  with  a  clean 
towel.     Protect  any  abrasion  on  the  hand  with  a  clean  ruJjber  gloN'e. 

If  there  is  any  break  in  the  protecting  epithelial  layer  of  the  vulva  or  vagina  or 
cervix,  or  if  the  interior  of  the  uterus  is  to  1)o  explored,  the  hands  should  be  further 
cleansed  in  1-2000  bichloride  or  other  reliable  antiseptic  solution  (i.  e.,  they 
should  be  put  through  the  regular  process  of  surgical  disinfection)  or  boiled  rubber 
gloves  may  be  slipped  on. 


PRECAUTIONS  AC.AINST  IN  I'ECI'K  ).N 


101 


Fig.  107.     A  simple  instrument  boiler. 


2.  Sterilize  the  Instruments.  This  may  be  accomplished  ]yy  .soakiii^r  tliciv  in 
pure  carbohc  acid  (95%)  for  ten  minutes  or  in  a  10%  carboUc  solutioirfor  tliirty 
minutes.     A  safer  plan  is  to  boil  them  for  five  or  ten  minutes. 

For  boiling  the  instruments,  a  1%  solution  of  sodium  carbonate  (wa.shing  soda) 
is  preferable  to  plain  water.  It  dissolves  the  resisting  capsule  of  l^actcria  and 
destro3's  them  more  quickly  (in  five  minutes  l)oiling)  and  also  tends  to  diminish 
rusting  of  instruments.  Any  kind  of  a  pan,  set  on  a  stove  or  over  an  alcohol 
lamp  or  gas  flame,  will  do  for  an  in- 
strument boiler.  The  ordinary  fish- 
boiler  of  granite-iron  makes  a  very 
good  instrument  sterilizer.  A  satis- 
factory simple  boiler  for  instruments 
is  shown  in  Fig.  107.  Nicer  and  more 
convenient  instrument  boilers  may 
be  purchased  as  desired.  There  are 
a  number  of  satisfactory  patterns. 
The  one  shown  in  Fig.  108  has  the 
advantage  that  the  ch-essings  for  a 
small  operation  may  be  sterilized  at 
the  same  time  with    the  instruments. 

In  office  or  clinic  work  when  through  examining  a  patient,  wash  the  instruments 
and  drop  them  into  the  boiler  and  in  a  few  minutes  they  are  sterilized,  ready  to  use 
for  another  patient  or  to  be  put  away.  Edged  instruments,  such  as  knives  and 
scissors  are  more  or  less  dulled  by  the  boiUng.     Consequently  when  there  is  plenty 

of  time,  it  is  better  to  sterilize  them  by 
soaking  them  in  carbolic  acid  or  other 
suitable  antiseptic.  When  a  knife  is 
put  in  with  other  instruments  for  ster- 
ilization the  cutting  portion  should  be 
wrapped  with  cotton. 

The     instrument    tray    also    must   of 
course   be   sterile.     It   is   contaminated 
every   time  a  soiled    instrument   is   laid 
back   in   it   and  unless  disinfected  may 
carry   disease   from  one  patient   to  an- 
other.   To  obviate  this,  each  instrument 
after   use   may  be  laid  on  a  clean  towel 
(if  it   is  to  be  used  again  during   that 
examination)  or  dropped   in  a  basin   for 
later  cleansing.     Again,  a  light  shallow  pan  may  be  used  as  an  instrument  boiler 
and  instrument  tray  combined,  the  instruments  being  boiled  in  it  each  time  before 
use.    This  gives,  in  a  few  minutes,  sterile  instruments  in  a  sterile  container. 

3.  Do  not  touch  the  intrauterine  part  of  any  instrument.  This  rule  should  be 
very  carefully  observed,  for  in  it  lies  one  of  the  secrets  of  avoiding  infection  of  the 
uterine  cavity  in  office  examination  and  treatment. 

The  hands  may  have  been  well  disinfected  or  they  may  have  been  covered  with 


Fig.  108.  A  small  instrument  and  dressing 
sterilizer.  The  dressings  for  a  small  operation 
may  be  sterilized  in  the  trays  above  the  boiling 
instruments. 


102 


THE  PHYSICAL  EXAMINATION 


Fig.  109.  The  articles  needed  for  preparing  for  the  gynecological  examination,  arranged  conveniently  on  a 
stand,  a.  Finger-nail  instruments,  b.  Rubber  gloves,  c.  Powder  for  dustir-g  in  rubber  gloves,  to  make  them 
slip  on  easily,  d.  Liquid  soap  in  a  drop-bottle,  e.  Hand  brushes,  f .  Bichloride  solution,  g.  Cotton  balls, 
h.  Lubricant  in  compressible  tube. 


Fig-  110.     Methpd  of  using  the  drop-bottle  coijtainiiig  licjuid  soap. 


ARTICLES  FOR  PREPARATION  OF  HANDS 


103 


boiled  rubber  gloves,  giving  a  perfectly  sterile  covering,  but  in  office  work  the 
field  of  examination  has  not  been  disinfected.  The  hands  necessarily  touch  un- 
disinfected  surfaces  and  hence  do  not  remain  sterile.  Consequently,  when  hand- 
ling an  instrument  for  intrauterine  work,  it  is  important,  even  when  wearing  rubber 
gloves,  to  observe  the  rule  not  to  touch  that  part  of  the  instrument  that  is  to  enter 
the  cervical  canal.  When  bending  the  end  of  the  uterine  sound,  dip  a  large  piece 
of  absorbent  cotton  in  a  reliable  antiseptic  solution  and  grasp  the  part  to  be  moulded 
with  that.  If  the  uterine  canal  is  to  be  cleansed  M-ith  a  cotton-wrapped  appli- 
cator, use  one  of  those  previously  prepared,  as  described  under  intra-uterine  treat- 
ment in  chapter  iii.  If  one  must  be  prepared  for  immediate  use, be  sure  to  cleanse 
carefully  the  fingers  that  touch  the  cotton  and  also,  before  introducing  the  cotton, 
dip  it  in  an  antiseptic  solution. 

The  other  antiseptic  precautions  necessary  in  intrauterine  exploration  and  treat- 
ment have  already  been  given. 


F 


SOAP,  BRUSHES,  LUBRICANT. 

Soap.     Use  some  liquid  preparation  of  green  soap.     The  free  use  of  such  a  soap 
is  the  most  important  step  in  hand  disinfection.     A  number  of  excellent  and  con- 
venient preparations  of  liquid  soap  have  been  put  on  the  market  by  various  firms, 
in  drop  bottles  (Fig.  109-d)  from  which  the  soap  may 
be  dropped  as  needed  without  waste.      Such  a  bottle 
may   be  filled  with  ordinary  tincture  of  green  soap 
(tincture  sapo    viridis)   or  any  other  required  prep- 
aration,   purchased     in    quantity    or    made  up  as 
desired.     Fig.  110  shows  the  use  of   the  drop  bottle. 
A  still  more  convenient  arrangement  is  the  stationary 
holder  for  liquid  soap,  fastened  just  above  the  wash- 
stand.     Fig.  Ill  shows  a  good  pattern.     Slight  up- 
ward pressure  against  the  projecting  stem    at    the 
bottom  causes  the  liquid  soap  to  flow  into  the  hand. 

Some  liquid  preparation  should  be  used  entirely 
for  soap.  The  ordinary  cake  soap  is  not  effective  for 
surgical  cleansing. 

Brushes.     For  cleansing  the  irregularities  about  the         ^^s-  m.    a  convenient  waii- 

°  fixture    for    liquid    soap.     Slight 

fingers,  a  brush   is  necessary.      The    ordinary  small      upward  pressure  on  tiie  metal 
hand-brush  of  vegetable  fiber  with  a  plain  back  (Fig.      ^^^-^  ^^  ^^e  bottom  causes  the 

soap  to  flow  into  the  open  hand. 

109-e),  does  very  well.     Such  brushes  are  cheap  and 

will  stand  boiUng  and  are  effective  as  long  as  the  fiber  portion  is  uniforml}'  stiff. 
When  a  brush  becomes  too  soft  from  repeated  boiling,  it  should  be  thrown  away 
or  laid  aside  to  be  used  on  surfaces  where  a  softer  brush  is  required,  such  as  the 
abdominal  surface  or  genitals  of  patient  being  prepared  for  operation. 

A  brush  used  in  scrubbing  the  hands  after  examining  an  infected  or  doubtful 
case,  must  be  boiled  before  being  used  again.  It  is  convenient  to  have  several 
brushes  boiled  and  kept  in  a  jar  ready  for  use.  They  may  be  kept  dry  or  in  an  anti- 
septic solution, 


104 


THE  PHYSICAL  EXAMINATION 


Lubricant.  A  drop  or  two  of  liquid  soap  on  the  wet  fingers  or  glove  makes  a 
most  satisfactory  lubricant.  The  smallest  quantity  lubricates  thoroughly  and  is 
in  a  measure  antiseptic  and  is  easily  removed.  Glycerine  I  do  not  find  satisfactory. 
Unless  used  in  such  large  quantity  as  to  be  inconvenient,  it  does  not  lubricate  well. 

In  the  absence  of  liquid  soap,  any  clean  unirritating  ointment  will  do.  When  an 
ointment  is  used,  it  is  well  to  have  it  put  up  in  a  compressible  tube  (Fig.  109-h), 
for  then  the  unused  part  is  kept  sterile. 

USE  OF  RUBBER  GLOVES. 

I  wish  to  call  attention  to  the  routine  use  of  rubber  gloves  in  examination  and 
office  treatment,  particularly  in  cases  where  any  infection  is  present  or  suspected. 


Fig.  112.     Patient  arranged  for  abdominal  exataination  in  bed. 


For  ordinary  office  work,  it  is  convenient  to  put  them  on  dry.     When  a  small 

amount  of  boric  acid  powder  or  talcum  powder  is  dusted  into  each  glove,  it  slips  on 
easily.  The  glove-covered  hands  are  then  put  through  the  regular  washing  with 
liquid  soap  and  water.  After  the  examination,  the  gloves  are  slipped  off  and 
thro^^^l  into  a  basin  for  subsequent  boiling.  Thus  the  infective  material  is  kept 
away  from  the  washstand  as  well  as  from  the  hands.  After  the  office  work  is 
finished,  water  is  poured  into  the  basin  of  soiled  gloves  antl  they  are  boiled  for 
ten  minutes.  It  is  well  to  have  a  towel  in  the  basin  to  protect  the  gloves  from 
injury  by  direct  contact  with  the  hot  metal  ])ottom  and  sides.  After  the  steriliza- 
tion, the  gloves  are  taken  out,  cleansed  in  water  to  remove  all  foreign  particles 
adhering  to  them,  dried  on  a  clean  towel  (being  tui-ned  inside  out  often  enough 
to  secure  good  drying),  dusted  inside  and  out  with  a  drying  ]-)Owder,  wrapped  in 


THE  USE  OF  RUHBEU  CLOVES 


105 


a  clean  towel,  and  laid  away  for  subsequent  use.  When  there  is  an  examination 
or  treatment  requiring  sterile  hands,  a  pair  of  the  rubber  gloves  is  wrapped  in  a 
small  towel  and  dropped  into  the  water  on  top  of  the  instruments,  to  be  boiled 
with  them.  When  putting  on  the  boiled  gloves  fill  them  with  sterile  water  to 
make  them  slip  on  easier.  When  no  cool  sterile  water  is  at  hand  for  distending 
the  glove,  a  drop  of  liquid  soap  rubbed  over  the  hand  will  enable  the  glove  to 
slip  on  easily.     In  putting   on    a  sterile  glove,  do  not  touch  the  fingers  of  the 


Fig.  113.  Patient  arranged  for  vaginal  examination  in  bed.  In  this  and  the  two  succeeding  photo- 
graphs, the  sheet  has  been  pushed  aside  to  show  the  necessary  relations.  As  a  rule  the  examination  can  be 
conducted  under  the  sheet  without  any  exposure  of  the  gentials. 


glove  with  the  other  hand.  When  it  is  necessary  to  push  the  glove  on  a  finger, 
use  a  portion  of  the  tow^el  in  which  the  gloves  were  boiled. 

Two  or  three  pairs  of  rubber  gloves,  kept  ready  for  use,  constitute  one  of  the  best 
investments  the  practitioner  can  make,  for  the  following  reasons: 

1.  They  protect  the  hands  from  syphilitic  or  other  infection  through  some  un- 
noticed crack  or  abrasion. 


106 


THE  PHYSICAL  EXAMINATION 


2.  They  prevent  disagreeable  odors  clinging  to  the  hands,  as  otherwise  happens 
in  vaginal  examination  in  cases  of  advanced  uterine  cancer  and  in  all  rectal  exam  - 
inations. 

3.  They  do  away  with  the  severe  scrubbing  of  the  fingers  and  hands,  which  is 
otherwise  necessary  after  each  examination  or  treatment  of  a  patient  with  any 
form  of  infection.  This  frequent  severe  scrubbing  keeps  the  skin  rough  and  in 
bad  condition. 

4.  Boiling  the  gloves  after  use,  eliminates  all  danger  of  carrying  contamination 
from  one  patient  to  another  and  keeps  the  infective  material  away  from  the  wash- 
stand  and  other  office  fixtures. 


Fig.  114.  Deep  bimanual  examination  with  the  patient  in  bed.  Showing  the  relations  of  the  examining  hand 
and  arm.  The  examiner  sits  on  the  side  of  the  bed  and  the  arm  lies  between  the  widely-separated  thighs,  so 
that  the  examination  is  made  from  directly  in  front  of  the  pelvis. 

5.  When  an  absolutely  sterile  covering  for  the  hands  is  desired,  it  is  easily  se- 
cured by  boiling  the  gloves  immediately  before  use. 


AVOID  UNNECESvSARY  EXPOSURE. 

In  all  the  steps  of  the  examination  and  in  all  examinations  and  treatments, 
avoid  exposing  the  patient  any  more  than  is  necessary.  Do  not  let  your  study  of 
the  clinical  and  scientific  features  of  the  case  so  preoccupy  your  mind  that  you 
neglect  this. 


OTHER  POINTS  IN  THE  EXAMINATION 


107 


The  carelessness  manifested  in  this  respect  by  some  physicians  Is?  extremely 
reprehensible.  This  careless  disregard  of  the  natural  modesty  of  the  patient  is 
seen  both  in  private  work  and  in  clinic  work  but  especially  in  the  latter,  where  it  is 
just  as  reprehensible  as  in  the  former.  To  the  physician  studying  the  difficult 
features  of  a  case  in  an  endeavor  to  save  the  patient's  life  or  restore  her  to  health, 
this  may  seem  a  small  matter — but  nevertheless  it  is  an  important  one  and  should 
be  thought  of.  Furthermore,  the  poor  patient,  who  in  the  clinic  puts  herself 
under  the  care  of  the  teacher  and  his  assistants,  is  just  as  much  entitled  to  thought- 
ful consideration  in  this  matter  as  the  woman  m  Ijettcr  financial  circumstances 
who  comes  as  a  private  patient. 

PRESERVATION  OF  SPECIMENS. 


The  preservation  of  speci- 
mens for  microscopic  examina- 
tion is  a  very  simple  proceed- 
ure  and  yet  in  many  doubtful 
cases,  curettings  or  cervical 
polypi  removed  or  pieces  of 
tissue  passed  spontaneously, 
are  thrown  away  or  kept  in 
such  a  manner  that  they  are 
not  fit  for  microscopic  exam- 
ination. Thus  is  lost  a  valu- 
able aid  to  early  diagnosis,  in 
conditions  where  early  diag- 
nosis is  important. 

A  good  all-around  preserva- 
tive for  these  specimens  is 
alcohol  (95%).  It  is  nearly 
always  at  hand  and  it  preserves 
the  specimen  indefinitely  in 
good  condition  for  microscopic 
examination.  As  soon  as  pos- 
sible after  removal  and  with- 
out unnecessary  handling,  the 
specimen  is  dropped  into  a 
small  bottle  containing  the 
preservative  and  then  for- 
warded to  the  pathologist. 

A  10%  solution  of  formol  is  another  good  preservative.  Formol,  which  is 
a  40%  solution  of  formaldehyde  gas,  is  known  also  as  formalin  and  as  formalde- 
hyde solution. 

For  particular  points  in  the  saving  and  transmission  of  curettings  for  diagnostic 
purposes,  see  previous  pages  (curetment  under  anesthesia). 


Fig.  115.  Deep  bimanual  palpation  with  tlie  patient  in  bed,  show 
ing  the  abdominal  arm  bettveen  the  thighs.  The  otiier  arm  is  partially 
hidden  by  the  sheet. 


108 


THE  PHYSICAL  EXAMINATION 


EXAMINATION  ON  BED. 

When  a  patient  is  seen  at  her  home,  sick  in  bed,  the  methods  of  exploration 
employed  are  usually  abdominal,  vaginal,  vagino-abdominal  and,  in  some  cases, 
recto-abdominal.  A  patient  who  is  too  sick  to  come  to  the  office  for  a  pelvic 
examination,  is  usually  suffering,  not  with  a  superficial  disturbance  that  can  be 
seen  by  inspection  of  the  external  genitals  or  through  a  speculum,  but  with  some 
(ieep-seated  trouble,  the  nature  of  which  can  be  determined  only  by  deep  internal 
palpation.    In  such  a  case ,  the  inspection  of  the  genitals  and  the  speculum  exam- 


c5:*'!^ 


Fig.  116.  Regular  "cross-bed"  position.  The  patient  is  turned  directly  across  the  bed,  with  the  hips  rest- 
ing on  the  edge  of  the  bed  and  each  foot  on  a  chair. 

ination  add  nothing  of  importance  to  the  information  otherwise  obtained,  and  as 
they  are  particularly  disagreeable  to  the  patient  they  may  be  dispensed  with. 

In  such  a  case,  the  abdominal  examination  is  first  made.  The  patient  is  di- 
rected to  move  to  the  edge  of  the  bed  and  the  clothing  is  loosened  and  pushed  up 
and  down,  to  expose  the  alxlomen,  and  the  knees  are  drawn  up  to  relax  the  ab- 
dominal muscles  (Fig.  112).  The  abdomen  is  then  examined  by  the  various  me- 
thods previously  explained. 

The  vaginal  and  vagino-abdominal  examinations,  with  deep  bimanual  palpation. 
may  be  conveniently  and  satisfactorily  conducted  with  but  little  disturbance  to 
the  patient  by  observing  the  following  directions,  some  of  which  were  partially 
carried  out  in  arranging  for  the  abdominal  examination: 


METHOD  OF  EXAMINATION  ON  BED 


109 


1.  Direct  the  patient  to  move  close  to  the  left  edge  of  the  bed.  There  is  but 
little  disturbance  —  she  lies  just  as  she  is  in  the  bed,  except  nearer  the  left  edge 
(or  the  right  edge,  if  the  examiner  uses  the  right  hand  for  the  internal  palpa- 
tion). A  patient  seriously  sick,  even  with  peritonitis,  may  usually  be  moved  over 
sufficiently  without  much  pain. 

2.  Remove  the  heavy  bed-clothing,  all  except  the  sheet  with  perhaps  a  light 
blanket,  and  have  the  patient  draw  up  both  knees  so  that  the  feet  are  near  the 
buttocks  (Fig.  113). 


Fig.  117.  Another  method  of  arranging  a  bed-patient  for  examination  of  external  genitals.  This  is  useful 
when  the  patient  is  very  sick  or  when  movement  is  painful.  The  hips  are  simply  slipped  to  the  edge  of  the 
bed  and  one  foot  placed  on  a  chair. 


3.  Sit  on  the  bed,  or  on  a  chair  placed  at  the  side  of  the  bed,  against  the  patient's 
left  foot  and  direct  the  patient  to  separate  the  knees  widely.  The  sheet  is  then 
raised  sufficiently  to  permit  the  examining  hand  (with  the  index  and  middle  fingers 
well  lubricated)  to  be  passed  between  the  patient's  thighs  (Fig.  114) — not  under 
one  thigh,  as  ordinarily  directed.  The  hand  is  carried  to  the  perineum  and  the 
examining  fingers  are  introduced  deeply  into  the  vagina,  taking  care  to  depress  the 
perineum  sufficiently  to  allow  their  introduction  without  pain. 

4.  After  the  simple  vaginal  examination  is  completed,  then  the  right  hand, 
passed  under  the  sheet,  is  made  to  depress  the  abdominal  wall  into  the  pelvis  as 
in  the  regular  bimanual  examination  (Fig.  115).     In  Figs.  113  and  114  and  115, 


110  THE  PHYSICAL  EXAMINATION 

the  sheet  has  been  pushed  aside  in  order  to  show  the  necessary  relations.  Ordi- 
narily the  entire  examination  may  be  conducted  under  the  sheet  and  without  ex- 
posing the  patient  in  the  least. 

I  call  special  attention  to  the  details  given  above  because  I  find  that  their  accu- 
rate carrying  out  aids  materially  in  securing  needed  information  in  deep-seated 
pelvic  troubles.  By  following  the  directions  closely,  the  examining  hands  and  arms 
are  made  to  occupy  practically  the  same  advantageous  relation  to  the  pelvis  as  in 
the  regular  office  examination  with  the  patient  at  the  end  of  the  table — that  is,  the 
examination  is  made  from  directly  in  front  of  the  pelvis.  The  usual  procedure 
of  sitting  on  a  chair  beside  the  bed,  with  the  examining  arm  passed  under  the 
thigh  (instead  of  between  the  thighs)  is  much  less  effective  when  deep  pelvic 
palpation  is  required. 

While  the  examination  steps  above  mentioned  are  generally  the  only  ones  re- 
quired when  the  patient  is  sick  in  bed,  there  are  some  cases  in  which  further  ex- 
amination is  advisable.  Whenever  the  patient  complains  of  sores  about  the  genitals 
or  of  itching  or  burning  or  profuse  discharge,  the  genitals  should  be  inspected  in 
a  good  light.  Likewise  in  any  case  in  which  it  is  thought  that  additional  infor- 
mation of  value  may  be  obtained  by  the  speculum  examination,  that  procedure 
should  be  carried  out. 

For  the  inspection  of  the  external  genitals  and  for  the  speculum  examination,  the 
patient  may  be  turned  across  the  bed  with  the  hips  near  the  edge  and  each  foot 
resting  on  a  chair  (Fig.  116).  This  is  often  referred  to  as  the  "cross-bed" 
position.  If  movement  of  the  patient  to  this  extent  is  likely  to  cause  pain,  she 
may  be  simply  turned  shghtly  and  one  foot  placed  on  a  chair  while  the  other 
foot  rests  on  .the  bed,  as  shown  in  Fig.  117. 


NON-QYNECOLOQIC  EXAMINATION  METHODS 

IN  GYNECOLOGICAL  CASES. 

The  physician  must  consider  the  whole  patient.  His  work  Is  to  ascertain  what 
is  troubling  the  patient — in  whatever  part  of  the  body  the  disease  may  be  located 
or  whatever  organ  or  organs  may  be  affected.  It  is  not  enough  to  find  one  well- 
marked  disease.  All  the  important  troubles  present,  both  organic  and  functional, 
should  be  found,  for  then  only  is  the  physician  in  a  position  to  judge  accurately 
as  to  how  far  each  disease  is  responsible  for  the  patient's  disaliility  and  what 
the    line    of    treatment -should    include   and  what  the  result  will  probably  be. 

To  do  this  the  physician  must  employ,  in  gynecological  cases,  various  methods 
of  examination  which  belong  to  other  departments  of  medicine,  and  the  detailed 
consideration  of  which  would  be  out  of  place  here.  1  will  simply  call  attention 
here  to  the  classes  of  patients  with  pelvic  symptoms  in  which    such    extra-gyne- 


EXAMINATION  OF  THE   URINE  UJ 

cologic  examinations  are  especially  required  in  the  course  of  diaf^nosis  or  treat- 
ment. The  examination  methods  to  which  1  wish  to  call  attention  are,  aside 
from  the     usual    {ihysical  examination  of  the  chest,  as  follows: 

Examination  of  Urine. 

Blood  Examination. 

Sputum  Examination. 

Examination  of  the  Nervous  Svstem. 


EXAMINATION  OF  URINE  IN  GYNECOLOGICAL  CASES. 

The  examination  of  the  urine  gives  important  information  as  to  the  metabolism 
of  the  body  and  as  to  the  condition  of  the  most  important  excretory  organs. 
In  the  following  cases  it  is  especially  important  that  the  urine  be  examined. 

1.  When  the  patient  is  seriously  sick  from  any  cause.  In  such  a  patient  it  is 
important  to  know  the  state  of  the  body  metabolism  and  excretion. 

2.  When  there  are  bladder  or  kidney  or  ureteral  symptoms.  Do  not  treat  the 
patient  for  weeks  or  months  for  frequent  painful  urination  or  pains  in  the  kidney 
region,  without  examining  the  urine  to  see  whether  or  not  there  is  a  local  lesion. 
And  when  there  is  trouble  in  the  urinary  tract,  make  frequent  examinations  that 
you  may  keep  posted  as  to  the  improvement. 

3.  When  the  patient  is  to  undergo  anesthesia,  either  for  operation  or  examina- 
tion. The  discovery  of  diabetes  mellitus  or  chronic  interstitial  nephritis  is  made 
with  much  more  satisfaction  to  yourself  and  much  better  prognosis  to  the  patient 
before  anesthesia  than  afterward,  when  the  patient  may  be  in  diabetic  coma  or 
urameic  convulsions.  Again,  in  the  milder  cases,  it  is  not  pleasant  to  be  obliged 
to  date  the  patient's  persistent  nephritis  from  your  operation  or  anesthesia,  when 
in  all  probability  it  was  there  before,  but  you  have  no  proof  of  it.  Again,  a  know- 
ledge of  the  patient's  kidney  function  may  cause  you  to  postpone  the  operation  or 
anesthesia  for  a  time,  until  the  temporary  disability  is  overcome. 

4.  In  doubtful  cases — cases  in  which  the  cause  of  the  patient's  local  symptoms 
or  general  debility  is  not  clear.  You  wonder  why  the  patient  does  not  pick  up  and 
improve  more  rapidly  under  your  excellent  treatment.  You  are  annoyed  by  the 
patient's  reiterated  complaint  of  the  bladder  irritability  or  the  loin-pain  or  the 
headaches  tliat  come  without  reason  or  the  digestive  disturbances  that  persist 
without  good  and  sufficient  cause. 

There  is  a  hidden  cause.  It  may  be  in  the  urinary  tract.  It  may,  on  the  other 
hand,  be  in  the  digestive  tract  or  in  the  blood  or  in  the  nervous  system  or  in 
the  lungs.     Find  it. 

BLOOD  EXAMINATION  IN  GYNECOLOGICAL  CASES. 

The  points  in  blood  exannnation  which  are  helpful  in  certain  patients  with 
gynecological  symptoms  are  the  hemoglobin  percentage,  the  red-cell  count,  leu- 
cocytosis,  poikilocytosis  and  certain  special  conditions  (Widal  reaction,  malaria 
Plasmodium,  pyogenic  bacteria  or  other  bacteria  in  the  blood). 


112  THE  PHYSICAL  EXAMINATION 

The  cla'sse*  )f  cases  or  conditions  in  which  definite  information  on  one  or  more 
of  these  points  may  be  of  material  assistance  are  as  follows: 

Marked  Anemia. 

Acute  Conditions  of  Doubtful  Character. 
Inflammation  of  Uncertain  Progress. 
Inflammation  with  Uncertain  Resistance. 

Blood  Examination  in  Marked  Anemia. 

In  gynecological  patients  with  marked  anemia,  there  are  three  conditions  in 
which  a  blood  examination  is  especially  useful: 

1.  When  the  cause  of  the  anemia  is  not  dear.  You  may  be  mistaken  in  your 
idea  that  the  persistent  anemia  and  increasing  weakness  is  due  to  the  chronic 
pelvic  disease.  Possibly  the  patient  has  one  of  the  various  forms  of  pernicious 
anemia.     An  examination  of  a  stained  specimen  of  the  blood  will  tell  at  once. 

I  remember  a  patient  whose  anemia  was  supposed  to  be  due  to  an  associated 
chronic  malaria  and  she  was  treated  for  that  many  months,  until  her  condition  be- 
came desperate.  When  I  saw  her,  there  were  some  pelvic  symptoms  but  not  suffi- 
cient to  account  for  the  deterioration  of  general  health.  Being  at  a  loss  to  account 
for  the  anemia  and  weakness,  and  finding  nothing  of  special  importance  in  the 
urine,  I  took  specimens  of  the  blood.  Examination  of  these  made  the  case  clear 
at  once.  There  was  an  advanced  leukaemia,  of  which  the  patient  died  within  a 
few  months.     The  pelvic  disturbance  had  nothing  to  do  with  the  serious  symptoms. 

In  a  doubtful  case,  if  not  prepared  to  make  the  blood  examinations  yourself, 
make  some  cover-glass  spread  preparations  of  the  blood,  pack  them  securely  in  a 
pill-box  or  other  suitable  container  and  mail  them  to  a  pathologist,  vnth.  a  brief 
statement  of  the  history  of  the  case. 

2.  When  anesthesia  or  an  operation  is  required.  In  a  patient  markedly  anemic, 
anesthesia  is  a  serious  matter  even  though  it  is  only  for  .  a  small  operation 
or  simply  for  examination. 

All  the  organs  are  below  par  and  some  condition  that  would  be  a  trivial  matter 
at  other  times  might  lead  to  a  fatal  termination.  A  red-cell  count  or  a  hemo- 
globin estimate  will  give  definite. information  as  to  the  oxygen  carrying  power  of 
the  blood.  If  the  hemoglobin  is  below  30%,  the  operation  or  anesthesia  should 
be  postponed  if  possible  until  the  patient  has  been  put  in  a  better  condition,  by 
the  administration  of  iron  and  such  other  tonics  as  are  indicated. 

3.  When  trying  to  overcome  serious  anemia.  In  such  a  case  a  hemoglobin 
fcsumate  or  blood  count  at  regular  intervals  will  show  definitely  the  effect  of  the 
treatment. 

Blood  Examination  in  Acute  Conditions  of  Doubtful  Character. 

There  are  .several'  conditions  arising  in  patients  with  pelvic  symptoms  in  which 
the  ascertaining  of  one  or  another  fact  concerning  the  blood  is  a  decided  help  in 
determining  the  cause  of  the  patient's  serious  illness. 

1.  Fever.     The  patient  has  persistent  fever  and  pelvic  disturl)ance,  but  the  cause 


EXAMINATION  OF  TllK  HLOOU  113 

is  not  altogether  clear.  Is  the  fever  due  to  uterine  or  pelvic  inflammation  from 
puerperal  or  non-puerperal  infection,  or  is  it  due  to  typhoid  fever  or  malaria? 

Malaria  may  usually  be  easily  excluded  by  the  administration  of  quinine,  but 
not  always.  Examination  of  the  blood,  taken  at  the  proper  time,  will  show  almost 
certainly  whether  the  trouble  is  typhoid  fever  (Widal  reaction,  no  leucocytosis) 
or  malaria  (plasmodium,  no  leucocytosis)  or  something  else. 

I  recall  two  cases  in  particular  in  which  I  felt  that  decided  help  was  given  by 
the  blood  examination.  I  was  called  to  see  a  patient  who  had  had  a  miscarriage 
several  days  before  and  during  the  past  two  days  there  had  been  considerable 
fever.  The  temperature  (forenoon)  was  101'.  Pelvic  examination  showed  no 
decided  pathological  condition.  The  local  conditions  seemed  about  as  they  should 
be  at  that  time  after  a  miscarriage.  When  I  saw  her  that  night  the  temperature 
had  gone  to  103*^,  but  was  subsiding.  There  was  evidently  serious  trouble  and  I 
made  arrangements  to  clear  out  the  uterus  the  next  morning.  That  night  when 
thinking  over  the  case,  for  I  was  somewhat  puzzled  by  it,  it  occurred  to  me  that  it 
might  be  typhoid  fever,  though  no  particular  evidence  of  this  had  l^een  noticed  in 
the  examination,  except  a  persistent  headache  out  of  proportion  to  the  fever. 
The  next  morning  the  temperature  was  again  lower  and  I  felt  safe  in  waiting  for  the 
report  of  the  blood  examination  before  disturbing  the  uterus.  A  good  Widal  re- 
action was  found  and  the  subsequent  course  of  the  disease  showed  it  to  be  typhoid 
fever,  from  which  the  patient  recovered  without  any  uterine  disturbance.  Par- 
ticular inquiry  revealed  the  fact  that  the  patient  had  been  feeling  "under  the 
weather"  for  some  days  before  the  miscarriage.  Possibly  the  miscarriage  was 
due  to  the  beginning  typhoid  fever,  though  of  that  I  am  not  certain. 

In  the  other  case  referred  to,  I  was  called  in  consultation  to  see  a  young  woman 
who  for  two  or  three  days  had  had  fever,  running  up  to  103°  and  104°  in  the  after- 
noon but  lower  in  the  morning.  The  patient  had  had  a  miscarriage  a  week  before 
and  examination  showed  a  subacute  gonorrhoea.  There  was  considerable  discharge 
and  gonococci  in  abundance  but  no  decided  evidence  of  a  septic  metritis  or  of  a 
periuterine  inflammatory  focus.  Because  of  the  regularity  of  the  fever  and  the 
absence  of  the  evidences  of  a  local  lesion  sufficient  to  account  for  it,  I  suspected 
typhoid  fever.  Blood  examination  showed  no  Widal  reaction,  neither  was  there 
a  marked  leucocytosis.  A  second  blood  examination  gave  the  same  result  except 
tnat  there  was  more  leucocytosis.  Typhoid  fever  was  thus  excluded.  I  then  sent 
the  patient  to  the  hospital  on  account  of  the  pelvic  trouble  and  in  a  short  time  there 
developed  unmistakable  signs  of  a  focus  of  pelvic  suppuration,  which  I  drained 
per  vaginam  with  satisfactory  result.  The  pus  from  the  abscess  showed  a  mixed 
infection,  but  principally  gonococci. 

2.  Pain.  There  is  severe  persistent  pain  in  the  pelvis  and  marked  tenderness, 
without  much  fever.  Is  the  pain  due  to  severe  pelvic  neuralgia,  or  other  functional 
nervous  disturbance,  or  to  bleeding  from  tubal  pregnancy.  Ordinarily  the  differ- 
ential diagnosis  is  easily  made  by  the  symptoms  and  physical  signs.  But  when  the 
blood  in  the  peritoneal  cavity  is  fluid  (no  induration)  and  not  of  sufficient  quantity 
to  seriously  affect  the  pulse,  the  pain  and  tenderness  (preventing  satisfactory  pelvic 
examination)  are  about  the  only  signs  present.  If  decided  hemorrhage  is  present, 
a  leucocytosis  may  be  found. 


114  THE  PHYSICAL  EXAMINATION 

When  the  pain  is  associated  with  fever,  a  marked  leucocytosis  (principally  poly- 
nuclear)  points  to  some  acute  inflammatory  trouble,  such  as  salpingitis  or  appen- 
dicitis. 

In  uncomplicated  pelvic  tuberculosis  or  tubercular  peritonitis  there  is  no  leu- 
cocytosis. 

In  certain  post-operative  conditions  leucocytosis  may  be  of  assistance  in  con- 
nection with  the  other  symptoms.  The  patient  has  abdominal  pains  and  there  is 
marked  distention  of  the  abdomen  and  vomiting  and  persistent  failure  to  secure  a 
bowel  movement.  Is  it  gaseous  distension  of  a  sluggish  bowel  or  intestinal  obstruc- 
tion? It  is  said  that  the  latter  condition  nearly  always  gives  a  leucocytosis  of  20,000 
within  the  first  24  hours,  while  in  simple  distension  the  leucocyte  count  is  but  little 
above  normal.  If  this  observation  proves  generally  true,  it  will  be  a  most  valuable 
help  in  the  early  differential  diagnosis  in  these  very  trying  cases. 


Blood  Examination  in  Inflammation  to  Determine  if  it  is  Spreading. 

Here  the  point  is  to  determine  the  presence  or  absence  of  marked  pathological 
leucocytosis,  and  the  important  thing  is  not  so  much  the  absolute  increase  of  leu- 
cocytes as  the  relative  increase  of  poly  nuclear  leucocytes.  In  physiological  leuco- 
cytosis, which  takes  place  under  many  ordinary  normal  conditions  (after  a  meal, 
after  a  cold  bath,  after  exercise,  during  pregnancy,  in  the  puerperium,  during 
menstruation),  the  relative  proportion  of  60%  to  75%  polynuclears  is  preserved. 
In  the  ordinary  pathological  leucocytosis  the  proportion  of  polynuclear  leucocytes 
runs  higher,  particularly  in  the  presence  of  pus. 

As  a  general  proposition  it  may  be  said  that  polynuclear  leucocytosis  is  present 
wherever  there  is  acute  resistance  to  the  spread  of  inflammation  or  irritation.  It 
is  present  then  in  practically  all  ordinary  inflammatory  lesions,  except  when  the 
acute  symptoms  have  subsided  and  the  absorption  has  ceased  (focus  is  well  walled 
off)  or  where  the  inflammation  is  so  very  virulent  that  the  body  resistance  is  over- 
whelmed and  there  is  little  reaction.  It  is  absent  in  uncomplicated  typhoid  fever, 
malaria,  tuberculosis,  influenza  and  measles. 

In  the  following  cases  the  blood  examination  may  help  some  in  determining 
whether  the  inflammation  is  seriously  spreading. 

1.  Acute  salpingitis  (non-puerperal).  The  patient  is  in  the  midst  of  a  primary 
attack  of  salpingitis  with  accompanying  pelvic  peritonitis,  or  there  is  an  acute 
exacerbation  of  an  old  salpingitis.  The  fever  is  running  moderately  high  and 
there  is  much  pain.  Is  it  safe  to  wait  for  the  interval  operation  to  remove  the 
diseased  structure  or  should  the  operation  be  carried  out  now  in  the  presence  of  this 
fresh  virulent  infection?  If  the  inflammation  is  subsiding,  the  former  plan  is  the 
better.  If  the  inflammation  is.  spreading  and  threatening  a  general  peritonitis, 
the  latter  plan  is  the  better. 

In  all  but  exceptional  cases,  the  ordinary  symptoms  and  examination  findings, 
if  carefully  worked  out  and  considered,  will  place  the  patient  decidedly  in  one  class 
of  the  other  and  with  far  more  certainty  than  will  a  blood  test.  In  some  doubtful 
cases,  however,  repeated  examination  of  the  blood  at  short  intervals,  to  determine 


EXAMINATION  OF  THE  SPUTUM  XX5 

whether  the  leucocytosis  is  rising  or  falUng,  will  aid  materially  in  deciding  the 
question. 

2.  Puerperal  sepsis.  Here  also  the  ordinary  examination  methods  furnish  the 
most  reliable  information  concerning  the  local  and  general  condition,  and  they 
must  not  be  neglected  or  slighted  in  the  false  hope  that  laboratory  tests  will  supply 
the  desired  knowledge. 

But  in  cases  that  are  still  dou])tful,  in  spite  of  careful  analysis  of  the  symptoms 
and  examination  findings,  considerable  help  may  in  some  instances  be  obtained 
by  repeated  examinations  of  the  blood  at  short  intervals  to  determine  whether  the 
leucocytosis  is  rising  or  falling,  and  to  determine  also  the  number  and  character 
of  the  bacteria  in  the  blood  at  different  times.  The  exact  determination  of  these 
two  facts  may  give  substantial  aid,  in  exceptional  cases,  in  directing  treatment 
and  in  prognosis. 

Blood  Examination  in  Inflammation  to  Determine  the  Vital  Resistance. 

Pathological  leucocytosis  means  resistance.  A  slight  inflammation  awakens  a 
slight  resistance  (slight  leucocytosis) .  A  severe  inflammation  awakens  a  strong 
resistance  (marked  leucocytosis),  if  the  patient  has  the  required  vital  force. 
There  are  exceptional  cases  in  which  the  infection  is  so  very  virulent  that  the  vitav 
forces  are  overwhelmed  and  offer  but  little  resistance,  but  these  cases  are  compar- 
atively infrequent.  In  ordinary  acute  inflammation  of  severe  grade,  a  good  leu- 
cocytosis means  good  body  resistance  and  reserve  force,  and  a  poor  leucocytosis 
means  poor  body  resistance.  This  is  the  case  particularly  with  inflammation  of 
the  serous  membranes,  including  the  peritoneum. 

This  fact  may  be  turned  to  account  in  cases  of  advanced  general  peritonitis 
that  are  not  seen  until  late  and  where  it  is  a  question  whether  an  operation  could 
possibly  do  any  good.  A  marked  leucocytosis  means  that  there  is  still  decided 
vital  resistance  and  there  is  a  chance  of  recovery  if  nature  is  judiciously  aided  in 
the  fight. 

The  ab  ence  of  well  marked  leucocytosis,  in  the  presence  of  this  severe  and  active 
inflammation,  means  that  the  patient's  reserve  force  is  exhausted,  and  operation 
would  probably  have  no  effect  except  to  hasten  death.  In  attaching  importance 
to  leucocytosis  in  a  patient  in  this  desperate  condition,  be  careful  that  you  be  not 
misled  by  the  leucocytosis  that  comes  "in  articulo  mortis.' 

SPUTUM  EXAMINATION  IN   GYNECOLOGICAL  CASES. 

The  two  points  of  importance  are  the  presence  or  absence  of  tubercle  bacilli  and 
the  presence  of  elastic  fibers,  indicating  destruction  of  lung  tissue. 

The  gynecological  cases  in  which  sputum  examination  is  required  are  those 
presenting  the  following  conditions: 

1.  Suspected  Pelvic  Tuberculosis.  Pelvic  tuberculosis  is  nearly  always  secondaiy 
to  a  tubercular  focus  elsewhere  in  the  body,  and  the  most  frequent  sites  of  the 
primary  focus  are  the  lungs  and  the  intestinal  tract.  The  patient  may  not  ac- 
knowledge that  she  has  a  cough,  it  is  so  slight.     But  the  direction  to  save,  in  the 


ig  THE  PHYSICAL  EXAMIXATION 

Dottle  that  is  given  her,  all  the  mucus  that  can  be  gotten  up  in  the  morning,  will 
usually  bring  sufficient  for  examination,  if  there  is  any  trouble  there. 

2.  Unwarranted  Emaciation  and  Debility.  The  patient  has  some  pehdc  distur- 
bance but  not  enough  to  cause  the  poor  general  health.  What  does  cause  it? 
Possibly  it  is  from  beginning  pulmonary  tuberculosis.  Determine  whether  or  not 
such  is  the  case. 


EXAMIXATIOX    OF    THE     XERVOUS    SYSTEM    IX     GYXECOLOGICAL 

CASES. 

That  portion  of  the  nervous  system  distributed  to  the  pelvis  furnishes  its  quota 
of  local  painful  disturbances  (neuralgia,  neuritis,  transferred  pains)  and  local  par- 
alyses, which  must  be  taken  into  consideration  in  the  diagnosis  and  treatment  of 
pelvic  diseases. 

There  are,  in  addition,  certain  general  cUseases  of  the  nervous  system  which 
cause  complaint  of  pelvic  symptoms  and  occasion  much  confusion  in  diagnosis. 
They  are  principally  four,  as  follows: 

Hysteria, 
Neurasthenia, 
H}'pochondria, 
Melancholia. 

The  recognition  of  these  chseases  depends  of  course  on  a  knowledge  of  the  cHnical 
manifestations  of  each  disease  and  a  careful  consideration  of  the  symptoms  pre- 
sented by  the  patient.  This  differential  diagnosis  cannot  be  taken  up  here.  My 
purpose  is  simply  to  call  attention  to  certain  classes. of  patients  -^ith  pehic  symp- 
toms in  which  this  special  investigation  of  the  nervous  system  should  be  carried  out. 
They  are  as  follows: 

1.  Very  ner\'ous  patients.  I  use  the  term  ''nervous"  in  the  ordinary  commonl}-- 
accepted  meaning  of  the  word.  The  patient  is  perturbed  more  than  one  would 
expect  under  the  circumstances.  She  may  be  simply  frightened  or  embarrassed 
or,  on  the  other  hand,  she  ma}''  have  some  decided  organic  disease  of  the  brain  or 
nervous  system,  or  some  functional  nervous  disturbance. 

The  patient  may  have  a  well  marked  pelvic  lesion,  but  that  does  not  cause  the 
evidences  of  an  unstable  nervous  system.     What  does? 

This  particular  consideration  of  the  nervous  system  need  not  necessarily  be 
made  at  the  first  ^^sit.  The  patient  may  be  observed  for  a  time,  and  possibly  it 
will  be  seen  that  the  nervous  manifestations  largely  disappear  as  acquaintance  is 
astablished.  As  long  as  the  nervous  symptoms  persist,  however,  they  constitute 
an  undetei-mined  factor  in  the  case,  with  a  possible  bearing  on  the  patient's  loss  of 
health. 

2.  Pelvic  Distress  without  Corresponding  Lesion.  The  complaint  of  a  gyne- 
cological affection  for  which  no  evidence  can  be  found,  not  even  tenderness,  may 
be  due  to  pronounced  hypochondria. 

The  persistent  manifestation  by  the  patient  of  a  fixed  idea  that  she  has  some 


EXAMINATION'  OF  THE  NERVOUS  SYSTEM  ]]J 

pelvic  disease,  which  in  fact  is  not  present,  may  be  due  to  beginning  melan- 
cholia. 

On  the  other  hand  such  complaints  may  be  due  to  a  deliberate  attempt  on  the 
part  of  the  patient  to  deceive  the  physician — hoping  thereby  to  secure  an  opinion 
that  would  be  useful  in  a  suit  for  damages  or  for  divorce,  or  hoping  that  the  physi- 
cian may  use  some  examination  method  or  treatment  that  would  lead  to  an  abor- 
tion. 

\'erily  the  diagnostician  must  be  well  balanced,  and  must  have  his  eyes  open  m 
all  directions. 


iis 


CHAPTER    II. 

GYNECOLOGIC  DIAGNOSIS. 

The  diagnosis  in  any  case  is  based  upon  the  symptoms  given  by  the  patient  and 
the  signs  found  on  examination.  It  should,  as  far  as  possible,  be  both  an  ana- 
tomical and  a  pathological  diagnosis — that  is,  it  should  state  the  location  of  the 
lesion  and  the  character  of  the  pathological  process. 

Method  of  Diagnosis. 

Accurate  diagnosis  is  much  facilitated  by  a  grouping  of  diseases  under  certain 
prominent  symptoms.  This  is  the  natural  method,  the  one  that  is  followed  un- 
consciously. The  prominent  sign  or  symptom  in  the  case  brings  to  mind  a  group 
of  diseases,  and  then  by  the  consideration  of  other  ascertained  facts,  the  diagnosis 
is  narrowed  down  to  one  or  two  diseases.  This  differentiation  should  be  made  as 
one  proceeds   with  the  examination. 

For  example,  suppose,  during  an  examination,  a  sore  (ulcer)  is  found  on  the 
external  genitals.  Immediately  arises  the  question,  "  Is  this  a  chancroidal  ulcer 
or  a  syphihtic  ulcer  or  a  tubercular  ulcer  or  a  malignant  ulcer  or  a  simple  ulcer?" 
Endeavor  to  settle  the  question  then  and  there.  Recall  the  facts  in  the  history 
bearing  on  the  differential  diagnosis.  Notice  the  characteristics  of  the  lesion. 
Are  there,  in  other  parts  of  the  body,  evidences  of  syphilis  or  tuberculosis  or  malig- 
nant disease?    Is  there  an  irritating  discharge,  that  could  cause  a  simple  ulcer?    . 

Each  important  sign  must  be  thus  critically  considered,  and  the  habit  of  doing  so 
should  be  assiduously  cultivated.  In  a  few  cases  the  diagnosis  is  apparent  from 
a  few  prominent  facts,  but  in  most  cases,  particularly  in  deep-seated  and  serious 
diseases,  the  diagnosis  must  be  established  by  a  critical  analysis  of  the  mass  of  in- 
formation obtained  in  the  history  and  examination.  It  is  this  critical  analysis, 
this  testing  and  elimination  of  diseases  that  do  not  stand  the  test,  that  makes  the 
difference  between  the  careful  diagnosis  and  the  snap  diagnosis,  between  a  real 
diagnosis  and  a  guess,  between  a  reliable  diagnostician  and  an  unreliable  one. 

This  effective  application  of  the  signs  to  the  diagnosis  should,  as  far  as  practi- 
cable, be  made  promptly  and  rapidly  as  they  are  encountered  in  the  examination. 
Though  in  a  systematic  histoiy  and  examination,  all  the  important  facts  are  sup- 
posed to  be  obtained,  yet  if  the  a})pli(;ation  of  the  symptoms  to  the  diagnosis  is 
made  as  oik;  proceeds,  .certain  points  of  pai'ticuhir  impori-aitce  in  the  diagnosis  in 
that  case  will  bo  given  tlie  special  attention  which  they  require.  Hence  the  im- 
portance of  haviug  mentally  stored,  and  ready  for  immediate  use,  the  diagnostic 
signifi(;ance  of  the  various  facts  brought  out  in  the  history  and  in  the  examination. 

The  following  resume  of  the  diagnostic  signiftcan(;e  of  certain  signs  and  symp- 
toms is  given,  not  as  a  complete  collection  of  the  diagnostic  points  in  the  various 


POINTS  IN  THE  ABDOMINAL  EXAMINATION 


H'J 


diseases,  but  simply  as  a  working  plan  for  the  lapul  difTcrentiation  of  (ho  more 
common  gynecological  affections  and  other  conditions  likely  to  l)e  confcnmded 
with  them.  The  rarer  diseases  and  the  less  common  diagnostic  points  and  tiio  con- 
ditions present  in  anomalous  cases,  may  be  found  in  the  appropriate  chapters. 


POINTS  IN  THE  ABDOMINAL  EXAMINATION. 

In  this  examination  the  abdomen  is,  as  already  explained,  subjected  to  inspec- 
tion, palpation,  percussion,  and,  in  exceptional  cases,  to  auscultation  and  mensu- 
ration. 

The  principal  points  of  diagnostic  importance  in  connection  with  the  al)doiiiiii;il 
examination  are,  in  the  order  in  which  they  are  encountered  in  the  examination, 
as  follows: 

Prominence  of  Abdomen, 
Movement  of  Abdominal  Wall, 
Discoloration  of  Abdomen, 
Tension  of  Abdomen, 
Tenderness  of  Abdomen, 
Mass  in  Abdomen, 
Area  of  Dullness  in  Abdomen. 


Fig.  118.     Obesity.     The  most  prominent  feature  in  thib  case  is  the  marked  Obesity— see    Fig.  121.     There 
is  also  a  fibroid  tumor  of  the  uterus  and  a  small  amount  of  ascitic  fluid. 


120 


GYNECOLOGIC  DIAGNOSIS 


PROMINENCE  OF  THE  ABDOMEN. 

Decided  prominence  of  the  abdomen  is  due  to  many  different  affections,  which 
may  be  conveniently  arranged  in  five  groups,  as  follows: 

A.  Some  Affection  of  Abdominal  Wall; 

B.  Something  in  Intestines;  '' 

C.  Something  in  Peritoneal  Cavity; 

D.  Some  Enlarged  Organ; 

E.  Tumor  from  Pelvis  or  Abdomen. 

A.     Abdominal  Prominence  from  Some  Affection  of  Wall. 

Obesity  (Fig.  118).  There  is  evidence  of  fat  deposit  in  other  parts  of  the  body. 
The  abdominal  wall  may  be  picked  up  as  a  thick  roll,  and  the  fingers  made  to  almost 
meet  beneath  (Figs.  119,  120),  showing  that  m.ost  of  the  prominence  is  due  to  the 
thickness  of  the  wall.     There  is  no  distinct  localized  mass,  hke  a  tumor  in  the  wall. 

Percussion  gives  resonance  all  over  the  abdomen.  Sometimes  a  distinct  "fat 
wave"  may  be  obtained,  but  it  may  be  distinguished  from  a  "  fluid  wave"  by  the 
expedient  shown  in  Fig.  36,  and  also  by  percussion.  In  some  cases,  when  the 
patient  stands,  a  distinct  roll  of  fat  drops  belov/  the  general  abdominal  contour, 
as  shown  in  Fig.  121. 

Fig.  122  shows  a  case  of  obesity  mistaken  for  ovarian  tumor  and  sent  to  a 
hospital  for  operation.  Fig.  123  shows  a  case  of  obesity  which  was  mistaken  for 
pregnancy. 


Fig.   119.     Testing   the   thickness  of  the  Abdominal  Fig.  120.     Testing  the  thickness  of  the  Abdominal 

Wall.     First  step.  Wall.      Second  step.     The  fingers  carried  beneath  the 

■vvall. 


PROMINENCE  OF  THE  ABDOMEN 


121 


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Fig.  122.  Obesity,  mistaken  for  ovarian  tumoi. 
This  patient  was  sent  to  a  hospital  for  operation  for  a 
suDposed  ovarian  cyst.     (Hirst  —  Diseases  of  Women.) 


Fig.  121.  Obesity.  Patient  standing.  Same  patient 
as  shown  in  Fig.  118.  Notice  the  thick  roll  of  subcu- 
taneous fat  that  drops  down  below  the  general  contour 
of  the  abdomen. 

Tumor  of  Wall.  There  is  a  distinct  mass, 
which  is  superficial  and  moves  with  the  wall 
and  is  apparenty  inseparably  connected  with 
it.  The  mass  may  be  picked  up  and  the 
fingers  approximated  beneath  it.  There  is  no 
apparent  connection  with  any  intra-abdominal 
"organ.  There  is  dullness  on  light  percussion, 
but  resonance  on  deep  percussion.  Fig.  124 
shows  a  tumor  of  the  abdominal  wall. 

Inflammatory  Mass  in  Wall.  Same  as 
tumor  with  evidences  of  inflammation  added 
—  pain,  tenderness,  fever  and,  in  some  cases, 
rodness  and  fluctuation. 

Some  years  ago  I  witnessed,  as  a  visitor,  an 


Fig.  123.     Obesity,  mistaken  for  pregnancy  by  pa- 
tient.    (Williams  —  Obstetrics.) 


122 


GYNECOLOGIC  DIAGNOSIS 


Fig.  124. 
(Montgomer 


A  Tumor  of  the  Abdominal  Wall. 
y  —  Practical  Gynecology.) 


operation  upon  a  supposed  strangu- 
lated ventral  hernia.  The  patient 
gave  a  history  of  a  long-standing 
sweHing  some  distance  to  the  left 
of  the  umbilicus.  This  suddenly- 
enlarged  and  became  painful,  the 
enlargement  being  accompanied  by 
abdominal  pain,  vomiting,  con- 
stipation and  evidences  of  inflam- 
mation in  the  mass.  The  patient 
was  brought  before  a  medical  class 
for  operation.  As  the  hernial  site 
was  evidently  infected,  it  was  de- 
cided to  open  the  abdomen  else- 
where and  deal  with  the  intestine 
through  the  clean  opening.  Ac- 
cordingly the  peritoneal  cavity  was 
opened  by  a  median  incision.  Ex- 
ploration showed  that  the  peri- 
toneal surface  of  the  abdominal 
wall  on  the  affected  side  was  per- 
fectly normal.  There  was  no  her- 
nia. The  trouble  was  an  abscess 
of  the  abdominal  wall,  probably 
resulting  from  the  suppuration  of 
a  tumor.     A  large  operative  open- 


Fig.   125.     A   small  Umbilical    Hernia,  with  a  relaxed  abdominal  w:ill.      (Ilirbt — Dis- 
eases of  Women.) 


PROMINENCE  FROM  RELAXED  WALL 


123 


ing  into  the  peritoneal  cavity  in  siicn  ctose  proximity  to  an  al^scess,  made  a  very 
uncomfortable  state   of  affairs  for  the  surgeon,  particiilarly  as  the  al)sccss  was  so 


Fig.  126.     A  large  Ventral  'Hernia   at   the  site  of  an  operation  scar.     (Hi.-sl 
— Diseases  of  Women.) 


Fig.  127.     The    Contour  of  a  Relaxed  Abdominal  Fig.    128.    Same    patient  (Fig.  127),  Standing.    Notice 

Wall,  with  the  patient  Recumbent  the  marked  Projection  of  the  Relaxed  Abdominal  Wall. 


124 


GYNECOLOGIC  DIAGNOSIS 


Fig.  129.  Median  grooving  of  the  abdominal  wall 
where  there  is  Separation  of  the  Recti  Muscles.  The 
wonian  is  represented  as  Ijang  on  her  back.  (Webster — 
Diseases  of  Women.) 


large  and  so  near  the  surface  that  it 
was  thought  necessary  to  open  it 
at  once.  It  was  opened  as  far  as 
possible  from  the  median  incision. 
The  patient  recovered. 

Ventral  Hernia.  There  is  a  dis- 
tinct localized  protrusion,  which  is 
most  pronounced  when  standing  or 
sitting,  and  diminishes  when  the 
patient  hes  do"WTi.  Coughing  makes 
the  mass  prominent  and  gives  a  dis- 
tinct impulse  to  it.  The  mass  is  re- 
sonant on  percussion,  when  contain- 
ing intestine,  and  is  partially  or 
wholly  reducible.  "When  the  mass 
is  reduced,  the  margin  of  the  open- 
ing may  be  felt.  Fig.  125  shows  an 
umbilical  hernia.  Fig.  126  shows  a 
ventral  hernia  in  an  operative  scar. 
When  strangulated  and  so  inflamed 
as  to  prevent  satisfactory  palpation, 
a  ventral  hernia  may  give  much 
trouble  in  diagnosis,  particularly  if 
it  contains  only    omentum. 


Relaxation  of   Wall. 

There  is  general  protru- 
sion of  wall  when  sitting 
or  standing,  which  large- 
ly disappears  when  pa- 
tient lies  do'UTi,  unless 
tympanites  is  pronounc- 
ed (Figs.  127,  128), 
On  palpation  the  walls 
are  lax  and  no  ab- 
normal mass  is  felt. 
The  abdomen  is  every- 
where resonant  on  per- 
cussion. 

Separation  of  Recti 
Muscles.  The  recti 
muscles  are  ordinarily 
held  firmly  together  by 
the  junction  of  the 
sheath  of  one  side  with 
that  of  the  other  side, 


Fig.  130.  Patient  with  marked  Separation  of  the  Recti  Mu.srlcs.  The 
illustration  shows  the  marked  bulginR  between  the  separated  recti 
as  the  head  and  chest  are  raised  from  the  table,  the  abdominal  muscles 
being  thus  made  to  contract.     (Webster  —  Z>««ea«es  o/  Women.) 


PROMINENCE  FROM  TYMPANITES 


125 


forming  a  strong  fibrous  septum  in  the  median  line.     In  some  cases  of  alidominal 
distension  from  pregnancy  or  a  tumor,  the  tissue  between  the  recti  muscles  is  great  ly 


Fig.  131.  Patient  with  mariied  Separation  of  the  Recti.  Tlie  photograpli  froiu 
which  this  illustration  was  made,  was  taken  as  the  upper  part  of  the  body  was  being 
raised  from  the  table.  The  physician's  fist  is  buried  in  the  gap  between  the  muscles, 
which  are  contracting.  In  this  case  there  was  pionounced  pendulous  abdomen.  As 
the  patient  lay  relaxed  on  her  back,  the  distance  between  the  muscles  at  the  level  of 
the  umbilicus  measured  five  and  one  half  inches.      (Webster — Diseases  of  Women.) 


\ 


J 


Fig.  132.  Tympanites,  mistaken  for  pregnancy  by  the  patient.  The  small  figure  in  the  upper  corner  shows 
the  internal  condition  as  determined  by  the  bimanual  examination,  the  uterus  being  of  normal  size. 
(Edgar— Practice  of  Obstetrics.) 


126 


GYNECOLOGIC  DIAGNOSia 


stretched  laterally  and  remains  so.  This  gives  a  wide  weak  place  between  the 
recti  muscles,  in  which  the  tissues  are  lax  and  thin  (Fig.  129).  When  the  patient 
raises  her  head  and  shoulders  from  the  pillow,  or  otherwise  makes  strong  intra-ab- 
nominal  pressure,  there  is  bulging  of  this  weak  portion  of  the  wall  between  the 
recti  (Fig.  130).  In  such  a  case,  the  hand  may  be  sunk  deeply  into  the  abdomen 
between  the  separated  recti  muscles  (Fig.  131). 


B.  Abdominal  Prominence  from  Something  in  Intestines. 

Gas  (tympanites).  This  may  cause  marked  prominence  when  associated  with 
relaxation  of  abdominal  wall.  There  is  no  distinct  mass  felt  on  palpation.  Per- 
cussion shows  hyper-resonance  over  all  the  abdomen.     There  are  usually  symptoms 

indicating  gastric  or 
intestinal  indigestion. 
Tympanites  is  fre- 
quently associated 
with  enteroptosis. 
Fig.  132  shows  tym- 
panites which  the  pa- 
tient mistook  for  preg- 
nancy. 

Fecal  Impaction. 
Fecal  impaction  may 
cause  localized  promi- 
nence in  any  part  of 
the  abdomen  but  it  is 
usually  situated  along 
the  course  of  the  colon. 
The  diagnosis  depends 
largely  on  the  exclu- 
sion of  other  causes 
of  enlargement,  the 
history  of  constipation 
and  the  effect  of  treat- 
ment directed  toward  clearing  out  the  intestinal  tract.  Have  the  patient  take 
a  purgative  until  free  bowel  movements  are  secured,  then  a  large  enema  and  then 
return  for  another  examination. 


Fig.  133.  Ascites.  A  moderate  amount  of  fluid  in  a  relaxed  abdomen. 
Notice  how  the  abdomen  spreads  out  at  the  sides.  (KeWy— Operative 
Gynecology.) 


C.    Abdominal  Prominence  from  Something  in  the  Peritoneal  Cavity. 

General  Ascites.  This  may  l)o  sliglit  (Fig.  133)  or  marked  (Figs.  134,135, 
136,  137).  In  ascites,!,  c.  free  fluid  in  the  peritoneal  cavity,  the  abdomen  is 
incUned  to  spread  out  at  the  sides  and  flatten  at  the  top.  There  is  usually  a  dis- 
tinct fluid  wave,  obtained  as  previously  explained  (Fig.  35),  which  may  be  dis- 
tinguised  fi'om  a  fat  wave  as  shown  in  Fig.  36.  When  the  patient  is  turned  on 
the  side  or  when  she  sits  or  stands,  the  area  of  dullness  changes,  because  the 
fluid  seeks   the  lowest  part  of  the  peritoneal    cavity.       (Figs.    185,    189,    190). 


PROMINENCE   FROM  ASCITES 


127 


Another  diagnostic  point  is  that  in  some  cases  where  there  is  free  fluid  in  the  peri- 
toneal cavity,  when  the  patient  stands  there  is  decided  protrusion  of  the  uiiibiH- 


Fig.   134.     Marked  Ascites.     Notice  the  gentle  slope  at  the  lower  and  upper  portions  of  the  abdomen.     In 
the  case  of  a  tumor  the  rise  is  usually  much  more  abrupt.     (Kelly — Operative  Gcnecology.) 


Fig.  135.  Extreme  Ascites.  In  the  patient  from  which  this  photograph  was  taken,  the  abdomen  was 
so  distended  with  fluid  that  the  wall  was  raised  higher  than  the  mesentry  would  permit  the  intestine  to  float, 
giving  dullness  about  the  umbilicus  as  well  as  elsewhere  (see  Figs.  191,  192).  The  rise  of  the  wall  from  below 
is  rather  abrupt.  There  is  also  edema  of  the  wall,  as  shown  by  the  persisting  groove  where  the  skirts  were  tied 
about  the  waist. 


128 


GYNECOLOGIC  DIAGNOSIS 


cus  (Fig.   138),  which  protrusion  disappears  when  the  patient   is  in  the  recum- 
bent posture. 

Encysted  fluid  (pus  or  serum  or  blood).  A  distinctly  Hmited  collection  of  fluid, 
walled  off  or  encysted,  may  be  present  in  peritoneal  tuberculosis  and  also  in 
abscess  from  salpingitis  or  appendicitis.  There  may  be  considerable  sohd  exu- 
date associated  with  the  swelling,  and  also  other  evidences  of  inflammation,  either 


Fig.  136.  Another  case  of  extreme  Ascites,  giving  dullness  about  the  umbihcus  aa 
well  as  in  the  flanks.  Notice  the  markedly  pyramidal  form  of  this  abdomen. 
{KiTst— Diseases  of  Women.) 


Fig.  137.     Another  case  of   extreme  Ascites,  giving  dullness  about  the  umblilicus  and 
and  showing  a  very  abrupt  rise  of  abdominal  wall  below.     (Rivai— Diseases  of  ]Vomen.) 


septic  or  tubercular.  The  diagnosis  between  the  two  forms  of  inflammation  may 
usually  be  readily'  made  from  the  history  and  the  accompanying  symptoms. 
Extra-uterine  pregnancy,  like  the  inflammatory  processes  just  mentioned,  may 
present  the  evidences  of  encysted  fluid.  P'or  the  points  in  differential  diag- 
nosis, between  extra-uterine  pregnancy  and  ordinary  pelvic  inflammation,  see 
chapter  xi. 


PROMINENCE  FROM  AN  ENLARGED  ORGAN 


12Q 


Pseudo=cyst  of  the  Lesser  Omentum.  Following  injuries  of  tlie  pancreas  or 
disease  of  the  same,  there  may  be  a  collection  of  flui.l  in  the  lesser  peritoneal  cav- 
ity, causing  prominence  of  the  abdomen  and  evidence  of  encysted  fluid.  The 
diagnosis  is  usually  made  during  the  progress  of  the  operation,  Jn  all  these 
cases  of  encysted  fluid  or  solid  exudate,  there  is  dullness  over  that  portion  of  the 
mass  lying  against  the 
abtlominal  wall  and 
resonance  elsewhere. 

D.    Abdominal    Prom- 
inence from  Some 
Enlarged  Organ. 

Uterus    pregnant 

(Fig.  139).  There  is 
dullness  over  the  mass 
and  resonance  at  the 
sides  (Fig.  181).  There 
is  no  change  of  outUne 
of  dullness  on  change 
of  position  of  patient. 
There  are  also  the  vari- 
ous signs  of  pregnancy, 
including  the  fetal 
heart  sounds  if  the 
pregnancy  is  far 
enough  advanced. 

Bladder  distended 
with  urine.  The  re- 
tention of  ,urine  to  such 
an  extent  that  the  dis- 
tended bladder  pro- 
duces a  distinct  prom- 
inenceof  the  abdomen, 
happens  occasionally 
in  pregnancy  with  re- 
tro-displacement of 
uterus  (Fig.  141),  in 
labor  (Fig.  140),  in 
pelvic  tumors  compressing  the  urethra  and  in  certain  nervous  affections.  There 
is  dullness  over  the  mass  and  resonance  at  the  sides.  There  is  usually  a  fre- 
quent desire  to  urinate,  with  the  passage  of  only  a  small  amount  of  urine.  But  there 
may  be  a  constant  dribbling  of  urine  due  to  over  distention.  If  the  bladder  be 
emptied  with  a  catheter  the  diagnosis  becomes  clear.  Use  a  long  soft-rubber 
catheter,  as  the  ordinary  female  catheter  may  be  too  short  to  reach  the  entrance 
of  the  bladder,  and  if  the  catheter  be  not  flexible  it  can  not  follow  the  devious 


Fig.  138.  Extreme  Ascites.  Patient  standing.  Notice  the  protrusion 
of  the  umbilicus,  which  is  pushed  out  by  tlie- fluid  behind  it  as  the  patient 
stands.     This  is  the  same  patient  shown  in  Fig.    135. 


130 


GYNECOLOGIC  DIAGNOSIS 


Fig.   139.    Contour  of  the  abdomen  in  Pregnancy,  with  patient  recumbent.     (Edgar — Practice  of  Obstetrics.) 


I  Top  o/si/mpht/sis 


/ 

i 

( 

■■     I 

I, 

Fig.  140.  Contour  of  the  abdomen  in  a  case  of  Dis- 
tended Bladder.  The  patient  is  in  labor.  Notice  how 
well  the  bladder  prominence  stands  out  from  the  general 
abdominal  prominence  due  to  the  pregnant  uterus. 
(Norris— ^m.   Text- Bool:  of  Obstetrics.) 

course  of  the  distorted  urethra.  Patients 
have  died  from  rupture  of  the  bladder  due 
to  unrecognized  over-distention  (Fig.  141). 

Spleen  enlarged  from  chronic  malaria,  leu- 
kemia or  other  cause. 

Liver  enlarged  from  malignant  disease, 
hypertrophic  cirrhosis  or  other  cause. 

Gall=bladder  enlarged  on  account  of  oc- 
clusion of  duct  and  distension  with  mucous 
secretion  and   inflammatory    exudate.      It 

sometimes  becomes  so  much  distended  a; )  to  form  a  large  cystic  mass  in  the  right 
aide  of  the  abdomen. 


Fig.  141.  Frozen  section  of  the  body  of  a 
woman  who  died  fiom  Rupture  of  a  Distended 
Bladder.  The  cau.se  of  (lie  re'eiition  of  urine, 
was  a  retroverted  uterus  four  months  preg- 
nant. (Norri.s— .-Iw.  Text-book  of  Obstetrics, 
from  Arch,  of  Oyn.) 


PROMINENCE  FROM  PELVIC  TUMOR 


131 


E.  Abdominal  Prominence  from  a  Tumor. 

A  tumor  projecting  up  from  the  pelvis  (Fig.  142).  Such  a  tumor  has  its  point 
of  attachment  in  the  pelvis,  the  free  margin  of  the  growth  extending  upward 
into  the  abdominal  cavity.    The  growth  may  be  either  cystic  or  solid.     There  is 


Fig.  142.     Contour  of  the  abdomen  in  a  case  of    large    Cystic    Tumor  (parovarian).     Notice  the  abrupt  rise 
of  the  abdominal  wall  at  both  the  lower  and  upper  portions.     (Kelly — Operative   Gynecology.) 


Fig.  14.3.     Contour   of   the  abdomen  in  a  case  of   large  Solid  Tumor  (uterine  fibroid).     The  irregularity, 
so  common  in  solid  tumors,  is  well  marked.     (Kelly — Operative  Gynecology.) 


dullness  over  the  mass  and  resonance  at  the  sides  (Fig.  1S2).  There  is  no 
decided  change  of  outline  of  dullness  with  change  of  position  of  patient,  except 
where  there  is  complicating  ascites.  There  are  found  also  the  usual  symptoms 
caused  by  the  particular  variety  of  pelvic  tumor  present. 


132 


GYNECOLOGIC  DIAGNOSIS 


The  ordinary  new  growths  that  project  up  from  the  pelvis  are: 
Fibroid  tumor  of  uterus  (Fig.  143). 
MaUgnant  tumor  of  uterus  (carcinoma,  sarcoma). 
Cj^stic  tumor  of  ovary  (ovarian  cyst,  Fig.  144). 
Cystic  tumor  of  broad  hgament  (parovarian  cyst). 
SoHd  tumor  of  ovary  (fibroma,  carcinoma,  sarcoma,  papilloma). 
Solid  tumor  of  bladder  (Fig.  145). 
Solid  tumor  of  rectum. 


Fig.  144.  Another  case  of  large  Cystic  Tumor.  Here  thie  tumor  (an  ovarian  cyst)  is 
extremely  large  and  the  rise  of  the  abdominal  wall  at  both  lower  and  upper  portions  is  very 
abrupt.     (Bovee — Practice  of  Gynecology.) 


Fig.  145.  Appearance  of  the  abdomen  in  a  case  of  Extrophy  of 
the  Bladder.  A  carcinoma  has  developed  in  the  <^leformed  and 
turned-out  bladder.     {Ke\\y— Operative  Gynecology.) 


A  tumor  connected 
with  some  abdominal 
structure  (Fig.  146). 
Such  a  tumor  has  its 
point  of  attachment 
in  the  abdomen  with 
the  free  margin  of 
the  growth  extend- 
ing toward,  and  some- 
times into,  the  pelvic 
cavity.  There  is  dull- 
ness over  that  portion 
of  the  mass  lying 
against  the  abdominal 
wall  and  resonance 
elsewhere,  unless  there 
be  associated  ascites. 
There  are  symptoms 
also  pointing  to  the 
organ  affected  and  the 
nature  of  the  growth. 

The  principal  tumors 
that  originate  in  the  ab- 
domen are: 


PROMINENCE  FROM  ABDOMINAL  TUMOR 


133 


Solid  tumors  of  the  caecum,  sigmoid,  or  other  parts  of  the  intestinal 

tract  (usually  malignant). 
Solid  tumor  of  the  stomach  (usually  malignant). 
Solid  tumor  of  the  liver  (usually  malignant). 
Solid  tumor  of  the  spleen. 
Solid  tumor  of  kidney. 
Solid  tumor  of  pancreas. 
Solid  tumor  of  retro-peritoneal  structures  (Fig.  146). 


Fig.  146.  Contour  of  the  abdomen  in  a  case  of  Retroperitoneal  Tumor  (sarcoma).  The  projecting  mass  in 
the  region  of  the  umbiUcus  is  well  shown.  The  outline  of  the  palpable  mass  and  also  the  area  of  dullness 
are  shown  in  Fig.  201.  (Patient  of  Dr.  Elsworth  Smith,  Jr.,  to  whose  kindness  I  am  indebted  for  this  photo 
graph.) 


Cystic  tumor  of  kidney. 

Cystic  tumor  of  pancreas. 

Cystic  tumor  of  omentum. 

Cyst  of  mesentery. 

Pseudo-cyst  of  lesser  omental  cavity. 


134  GYNECOLOGIC  DIAGNOSIS 


MOVEMENT  OF  ABDOMINAL  WALL. 

In  certain  cases  some  information  may  be  obtained  by  watching  the  movements 

of  the  abdominal  wall. 

In  painful  affections  within  the  abdomen,  such  as  peritonitis  or  intra-peritoneal 
hemorrhage  or  intestinal  obstruction,  the  wall  is  held  rigid  to  a  considerable  extent 
and  the  respiratory  movements  of  the  wall  are  very  slight. 

In  the  case  of  a  tumor  splinting  the  wall,  the  portion  of  the  wall  raised  by  the 
tumor  remains  stationary,  while  the  remainder  shows  the  respiratory  movements. 

It  is  important  to  know  whether  or  not  a  tumor  moves  with  respiration. 
As  a  rule  a  tumor  of  an  abdominal  organ  moves  up  and  dow^n  with  the  dia- 
phragm in  respiration,  and  this  up  and  down  movement  may  often  be  dis- 
tinctly seen  and  felt  through  the  wall  at  the  lower  margin  of  the  growth  or  at 
the  prominent  part  of  the  mass.  If  the  tumor  is  firmly  adherent  to  the 
wall,  this  movement  under  the  wall  can  not  then  take  place.  In  some 
cases  this  fact  may  be  turned  to  account  in  determining  the  presence  or 
absenje  of  adhesions.     A  growth  from  me  pelvis  does  not  move  with  respiration. 

Movement  of  the  child  may  sometimes  be  plainly  indicated  in  late  pregnancy 
by  a  prominence  moving  beneath  the  wail,  due  to  an  extremity  moving  from 
3ne   part  of  the  uterus   to  another  and  pushing  out  the  wall  as  it  moves. 

Occasionally  the  intermittent  contraction  of  a  pregnant  uterus  may  be  noticed 
by  its  raising  the  wall  as  it  becomes  firmer  and  more  prominent. 

Pulsation  of  the  abdominal  wall  may  be  due  to  an  aneurysm.  Not  infrequently, 
especially  in  thin  patients,  the  pulsations  of  the  normal  aorta  are  transmitted  to 
the  overlying  wall,  either  directly  or  through  an  intervening  tumor. 

In  some  cases  of  intestinal  obstruction  or  marked  tympanites,  a  distinct  peri= 
staltic  wave  may  occasionally  be  seen  to  pass  across  the  abdomen  in  the  course 
of  the  distended  bowel.     It  is  usually  accompanied  by  a  cramp-like  pain. 


DISCOLORATION  OF  ABDOMINAL  SURFACE. 

Occasionally  there  is  a  well-marked  central  line  of  pigmentation,  extending  from 
the  pubes  to  the  umbiUcus  (Fig.  20).  This  is  usually  the  result  of  a  previous 
pregnancy. 

Dilated  veins  at  the  lower  part  of  the  abdominal  surface,  as  a  rule  mean  that 
there  is  some  mass  compressing  the  intra-pelvic  veins. 

Edema  of  the  wall  may  be  due  to  inflammation  in  the  wall,  or  to  heart  or  liver 
or  kidney  disease. 

Striae  (Fig.  18)  from  a  former  stretching  of  the  wall,  usually  mean  a  former 
pregnancy  continuing  to  near  term,  but  they  may  come  from  any  large  tumor  or 
from  a  former  obesity  of  the  abdominal  wall.  Such  striae  are  occasionally  seen 
on  the  thighs  of  patients  who  have  been  stout. 

When  the  wall  is  relaxed,  i.  e.,  has  been  overstretched  and  has  not  regained 
its  tone,  it  is  very  uneven  and  the  skin  appears  wrinkled  and  corrugated.  This 
folded  redundant  condition  is  nearly  always  present  in  decided   enteroptosis. 


TENSION  OF  THE  ABDOMEN 


185 


The  eruption  of  secoiidaiy  syphilis  (syphiHtic  roseohi)  is  occasionally  of  decided 
help  in  deterniiuiiig  the  character  of  an  atypical  vulvar  lesion.  An  eczema  or 
other  eruption  near  the  site  of  a  proposed  operative  incision,  may  necessitate 
postponement  of  the  operation  until  the  eruption  is  removed. 

A  scar  indicates  tliat  there  was  at  one  time  a  burn  or  a  blister  or  an  ai'ca of  ulcera- 
tion of  the  Avali  or  an  injury  of  the  wall  or  an  operative  incision  (Fig.  IGO). 


TENSION  OF  ABDOMEN. 

Tension  of  the  abdominal 
wall  interferes  very  much 
with  a  thorough  pelvic  ex- 
amination. It  is  due  to  one 
of  the  following  conditions: 

Fear  or  timidity  or  em= 
barrassment,  causing  the  mus- 
cular wall  to  be  held  tense. 
This  tension  usually  disap- 
pears as  the  examination  pro- 
gresses and  the  patient  sees 
that  you  are  not  going  to  cause 
pain.  Even  in  very  trouble- 
some cases,  relaxation  of  the 
wall  may  usually  be  secured 
by  directing  the  patient  to  take 
a  full  breath  and  then  let  the 
breath  all  out.  During  ex- 
piration, when  not  forced,  the 
wall  relaxes  and  deep  palpation 
may  be  made.  In  sinking 
the  fingers  into  a  region  or 
about  a  mass  for  palpation, 
proceed  gently  and  firmly  and 
steadily  toward  the  desired 
point,going  a  little  deeper  with 
each  expiration.  Do  not  gouge 
or  jab  or  endeavor  to  reach 
the  depths  of  a  region  by 
sudden  forced  movements. 
These  all  invite  failure  by  causing  reflex  contraction  of  the  abdominal  muscles. 

Inflammation,  local  or  general,  beneath  the  wall  causes  tension  of  the  over- 
lying muscles.  This  tension  is  usually  both  voluntary  and  involuntaiy.  The 
patient  can  relax  the  wall  to  some  extent  but  not  entirely,  providing  the  inflam- 
mation is  acute  and  severe.  There  is  also  marked  tenderness  over  the  affected 
area  and  other  evidences  of  an  inflammatory  affection. 

Mass,  solid  or  containing  fluid.      If  lying  immediately  beneath  the  wall  this 


Fig.  147.  The  Right  Lower  Abdomen.  The  organs  com- 
monly affected  and  the  areas  accordingly  of  particular  inter- 
est, are  indicated  by  tlie  stippling 


136 


GYNECOLOGIC  DIAGNOSIS 


gives  a  sensation  of  tension  or  resistance  to  the  palpating  fingers.  In  exceptional 
cases,  as  in  an  extra  large  tumor  or  very  marked  ascites,  the  abdomen  may  be 
so  filled  that  the  outer  abdominal  wall  is  stretched  and  tense. 

Hysterical   contraction    of  the  muscular   wall  is  sometimes  seen.    When  taking 
place  in  an  irregular  way  (part   contracted  and  part  relaxed)   and   associated 


Fig.  148.     Indicating  the   point   to  seek  for  Tender-  Fig.  149.      Palpating     for   Tenderness  or  a  Mass 

ness  due  to  Tubal  or  Ovarian   disease  of  tlie  right  side.         in  tlie  Right  Tubo-ovarian  region. 


Fig.  150.     Indicating  the  point  to  seek  for  Appendix  Fig.  151.     Palpating   for   Tenderness   or   a    Mass  in 

Tendemeea.  the  Appendix  Region. 


TENDERNESS  IN  ABDOMEN 


137 


with  tympanitic  distension  and  with  marked  hyperesthesia,  it  may  cause  the 
condition  known  as  "phantom  tumor,"  which  has  led  to  so  many  serious  mis- 
takes in  abdominal  diagnosis.  The  administration  of  a  purgative  to  clear  out  the 
intestines  and  diminish  the  tympanites  and  of  some  nerve  sedative  to  diminish 
the  hyperesthesia  and  nerve  irritability,  may  remove  the  tension  sufficiently  to 
admit  of  a  satisfactory  examination.  If  not,  the  patient  should  be  examined 
under  anesthesia,  provided  the  symptoms  are  serious  enough  to  make  a  positive 
diagnosis  necessary  at  once.  Under  anesthesia  the  tension  of  the  abdominal 
wall  disappears,  and  deep  palpation  may  be  made  in  the  affected  region  and  the 
presence  or  absence  of  an  abnormal  mass  determined. 


Fig.  152.  Palpating  for  the  Appendix  itself,  to 
determine  whether  or  not  there  is  any  appreciable 
infiltration  and  thickening  of  it.  When  thickened,  the 
appendix  is  felt  as  a  small  tender  roll,  deeply  placed. 


Fig.  153.  Another  method  of  palpating  the  Appendix. 
Beginning  near  the  umbilicus,  the  fingers  are  carried  in 
deeply  and  then  brought  slowly  outward  toward  the 
anterior  superior  iliac  spine.  .\s  the  appendix  passes 
under  the  examining  fingers,  it  is  felt  as  a  small  roll 
between  the  fingers  and  the  posterior  abdominal  wall. 


TENDERNESS  IN  ABDOMEN. 

For  the  purpose  of  studying  the  significance  of  tenderness  in  the  abdomen,  it  is 
convenient  to  divide  thecavity  as  previously  explained, into  nine  regions:  the  right, 
left,  and  central  portions  of  the  lower  abdomen;  the  right,  left  and  central  por- 
tions of  the  upper  abdomen;  the  central  portion  of  the  abdomen  (umbilical 
region);  and  the  right  and  left  lumbar  legions  (Fig.  30). 

In  any  of  these,  a  local  tenderness  takes  on  particular  significance. 

Again,  there  are  certain  diseases  that  cause  a  diffuse  tenderness,  extending 
throughout  the  whole  abdomen, 


138 


GYNECOLOGIC  DIAGNOSIS 


Fig.  154.  Indicating  the  site  to  search  for  Tenderness  of  the  Right 
Ureter.  This  may  be  found  anywhere  from  the  point  indicated  to 
some  distance  inside  the  circle,  towards  the  umbilicus. 


Appendicitis.  Tenderness  is 
most  marked  at  about  the  middle 
of  a  line  drawn  from  the  right 
iliac  spine  to  the  umljilicus 
(McBm-ney's  point,  Figs.  150, 
151) .  By  sinking  the  fingers  deep- 
ly into  the  abdomen  near  the  um- 
bilicus and  then  carrying  them 
outward  toward  the  iliac  spine, 
the  appendix  may  often  be  felt 
to  roll  under  the  fingers  as  a  tender 
cord  (Figs.  152,  153).  There  is 
usually  a  history  of  stomach  or 
bowel  disturbance  and  of  attacks 
of  pain  radiating  about  the  um- 
bilicus and  finally  settling  down 
in  the  appendix  region. 

Some  Disease  of  the  Caecum 
or  Ascending    Colon.   Inflamma- 


Tenderness  in  Right 
Lower  Abdomen 

(Fig.  147). 

Tubal  or  Ovarian  or 
Broad  Ligament  Disease 

(inflammation,  tumor, 
extrauterine  pregnan- 
cy) .  The  tenderness  is 
most  marked  low  in 
the  side  near  Poupart's 
ligament  (tubo-ovarian 
region.  Figs.  148,  149) . 
It  does  not  ordinarily 
extend  to  the  appen- 
dix region  though  it 
m  a  y ,  in  exceptional 
cases,  involve  both  re- 
gions. A  mass  may  be 
felt  on  vagino -abdom- 
inal palpation  between 
the  uterus  and  the  pel- 
vic wall.  There-;  is  a 
history  of  uterine  and 
pehic  inflammation  or 
other  pelvic  disturb- 
ance. 


Fig.  155.      PaliJiUing    for    Teucteruesa    or    Thickening 
about  the  Right  Ureter. 


TENDERNESS  IN  RIGHT  LOWER  ABDOMEN 


1:5!) 


tion,  tumor  ami  intussusccptiou  mv  the  more  cDiuiiion  alYcctifHis  of  the  caccuiii. 
Tliey  present  iiiucli  the  same  local  signs  as  mild  a[)pen(liritis.  The  tenderness  and 
the  mass  are  not  localized  to  the  appendix  region,  however,  hut  extend  up  along 
the  ascending  colon. 

Ureteritis.  There  is  a  painful  point  over  the  ureter  (Figs.  154,  155)  and  tender- 
ness extending  up  and  down 
the  course  of  the  same  (Fig. 
147).  There  is  usually  pain 
extending  from  the  kidney 
along  the  ureter,  to  the  hlad- 
der.  There  is  nearly  always 
decided  tenderness  over  the 
kidney  (Figs.  162,  163  and 
164). 

Movable  Kidney.  A  rounded 
mass  is  felt  on  deep  palpation 
in  or  near  the  appendix  region. 
It  is  somewhat  tender.  It  is 
movable  and  may  be  displaced 
upward  into  the  kidney  region. 
Special  methods  for  palpating 
same  are  shown  later  (Figs. 
413,  414).  There  is  a  history 
of  irritable  bladder,  particu- 
larly when  standing  or  w^alk- 
ing.  There  may  be  pain  radiat- 
ing from  the  kidney  region 
along  the  ureter  to  the  bladder. 
The  urinary  findings  will  indi- 
cate whether  or  not  there  is 
inflammation  or  irritation 
along  the  urinary  tract. 

Kidney  disease,  for  example, 
a  tumor  or  tuberculosis  or  in- 
flammation, may  cause  tender-        „.     ,„     _,,     t  f^  t  auj  tu  i,. 

'  -^  Fig.  156.     The   Left   Lower   Abdomen.     The   organs  commonly 

neSS    extending    from    the    kid-      affected   and    the    areas    accordingly   of    particular    interest,  are 

ney  down  into  the  right  lower    '''^''■'^^  ^^  *^«  ^*'pp"'^^- 
abdomen.      Kidney   disease  is 

indicated  by  tenderness  and  enlargement  found  in  palpation,  and  by  the  urin- 
ary findings. 

Intestinal  Disease.     Painful  diseases   of    the    small   intestine,    either    acute  or 
chronic,  may  give  rise  to  tenderness  in  the  right  lower  abdomen. 

Tubercular    Peritonitis    and    other  forms  of  peritoneal   disease  occasion  tender- 
ness here,  when  extending  to  this  region. 

Nervous  affection.  Various  organic  and  functional  nervous  diseases  cause  marked 
hj^ersensitiveness  of  the  abdominal  surface  and  of  the  intra-abdominal  struc- 


140 


GYNECOLOGIC  DIAGNOSIS 


Fig.  157.     Palpatating   for  Tenderness    or  a   Mass  in  the  Left 
T'jbo-ovarian    region. 


tenderness  in  the  left 
lower  abdomen  are  the 
same  as  those  just  given 
for  the  right  lower  ab- 
domen, substituting  the 
sigmoid  flexure  and  the 
descending  colon  for  the 
appendix,  caecum  and 
ascending  colon.  Fig.  157 
shows  palpation  for  left 
tubo-ovarian  tenderness 
and  Fig.  158  indicates 
the  point  for  left  ureteral 
tenderness. 

Tenderness  in  Central 
Lower  Abdomen 

(Fig.  159). 

Intestinal  Disease. 

There  are  many  affec- 
tions of  the  intestines 
that  give  pain  on  pres- 
sure in  the  central  lower 
abdomen,  for  example, 
ordinary    enteritis,   mu- 


tures.  The  pain  complained 
is  out  of  proportion  to  any 
obvious  sign  of  disease.  By 
palpating  over  the  abdomen 
it  is  found  that  there  is  ten- 
derness ever}' where,  even  up 
on  the  chest  walls.  Pinch- 
ing" up  the  skin  may  cause 
almost  as  much  pain  as  the 
pressure  on  deeper  struc- 
tures. General  observation 
of  the  patient  will  show  that 
she  is  nervous.  Special  ex- 
amination will  show  evi- 
dence of  neurasthenia, 
hysteria  or  other  disease 
of  the  nervous  system. 

Tenderness  in  Left  Lower 

Abdomen  (Fig.  156). 
The  affections  that  cause 


Fig.  158.     IndicatinK  the  place  to  search    for  Tenderness  or  Infiltra- 
tion about  tlie  Left  Ureter, 


TENDERNESS  IN  CENTRAL  LOWER  ABDOMEN 


141 


ecus  enteritis,  tubercular  enteritis  and  typhoid  fever.  The  tenderness  is  wide- 
spread, usually  extending  into  the  upper  part  of  the  abdomen.  There  are  also  the 
gastro-intestinal  symptoms  that  accompany  these  diseases  and,  in  addition,  the 
symptoms  and  signs  peculiar  to  each  disease. 

Inflammation  of  Uterus.  The  tenderness  is  confined  to  the  central  part  of  the 
lower  abdomen  (Fig.  160)  and  is  elicited  usually  only  by  deep  pressure.  There 
are  also  the  various  special  evidences  of  uterine  infiamniation. 


Fig.  159.     The  Central  Lower  Abdomen,  showing  the  organs  com- 
monly affected  by  local  disease. 


Pelvic  Inflammation.  Pelvic  inflammation  in  any  form  is  likely  to  give  rise  to 
tenderness  extending  throughout  the  lower  abdomen.  Even  if  the  inflammation 
is  confined  strictly  to  the  tube  on  one  side,  there  is  usually  some  tenderness 
on  pressure  in  the  median  line.  There  is  a  history  of  pelvic  inflammation, 
with  characteristic  tenderness  of  the  affected  adnexa  in  the  bimanual  examination, 
and  perhaps  also  a  distinct  mass. 


142 


GYNECOLOGIC  DIAGNOSIS 


Bladder  Disease.  The  tenderness  is  very  low,  just  above  the  pubes  (Fig.  161). 
There  is  a  history  of  frequent,  painful  urination.  Pressure  on  the  affected 
region  may  cause  a  desire  to  urinate.  Examination  of  the  urine  will  show  evidences 
of  bladder  or  kidney  disease. 

Tubercular  Peritonitis.  This  tenderness  is  widespread  over  the  abdomen. 
There  is  encysted  fluid  or  a  mass  of  exudate  or  general  ascites.  The  trouble  is 
usually  chronic.  There  may  be  evidence  of  tuberculosis  elsewhere  (lungs,  intestines) . 
There  is  no  apparent  focus  of  ordinary  infection,  such  as  salpingitis  or  appendicitis. 


^^t£f^f^f3r  '^^)r 


Fig.  160.  Indicating  the  place  to  seek  for  Tenderness  of  tbeUterus. 


Tenderness  in  Right  or  Left  Lumbar  Region. 

Renal  and  Suprarenal  affections  are  the  pathological  conditions  peculiar  to 
the  lumbar  regions,  and  the  usual  cau.ses  of  tenderness  there.  Fig.  162  shows 
the  point  to  seek  for  kidney  tenderness  in  front.  Fig.  163  indicates  the.  point 
in   the  lateral  lumbar  region  to  make  pressure  for  kidney  tenderness,  and  Fig. 


TENDERNESS  IN  UPPER  ABDOMEN 


143 


164  shows  the  point  posteriorly.  Fig.  165  shows  the  area  for  kidney  tender- 
ness in  the  left  lumbar  region,  and  Fig.  166  shows  the  method  of  palpating  for  a 
mass  in  the  same  region,  one  hand  being  placed  behind  and  the  other  in  front  bo 
as  to  catch  the  structure  l>etween  the  palpating  fingers. 

Tenderness  in  Right   Upper  Abdomen  (Fig.   167). 

Diseases  of  the  QaU=bladder  or  of  the  Liver  are  the  common  causes  of  tender- 
ness in  the  right  upper  alxlomen,  the  usual  condition  Ijeing  cholelithiasis  or  hepa- 


Fig.  161.    Indicating  the  region  to  palpate  for  Bladder  Tenderness. 


titis  or  tumor  of  the  liver.  Fig.  168  indicates  the  point  to  seek  for  gall-bladder  ten- 
derness. It  may  be  found  anywhere  from  thepoint  indicated  by  the  finger  out- 
ward to  the  costal  margin.  The  characteristic  gesture  of  liver  tenderness  (firm 
pressure  over  the  liver)  is  shown  in  Fig.  13,  while  Fig.  169  shows  the  method  of 
palpating  for  general  liver  tenderness.    Occasionally  an  affection  of  the  pyloric  end 


144 


GYNECOLOGIC  DIAGNOSIS 


Fig.  162.     Indicating  the  region  for  Kidney  Tenderness  in  Front, 
on  the  right  side. 


of  the  stomach  or  of  the 
duodenum  or  of  the  hepatic 
flexure  of  the  colon  or  of 
the  right  kidney,  causes 
tenderness  extending  well 
into  the  right  upper  ab- 
domen. But  in  practically 
all  these  conditions  the 
tenderness  may  be  traced 
out  of  this  region  and  for  a 
considerable  distance  along 
the  organ  affected. 

Tenderness    In    Left  Upper 
Abdomen  (Fig.  170). 

Diseases  of  the  spleen  or 
of  the  splenic  flexure  of  the 
colon  or  of  the  cardiac  end 
of  the  stomach  or  of  the  left 


Fig    163.      The     point      for      Kidney      Teuderneaa  Fig.  164.     The  point  for  Kidney  Tenderness  Posteriorly. 

Laterally. 


PALPATINd  THE  LUMHAll  REGIONS 


14  5 


Fig.  165.     The  area  for  Left  Kidney  Tenderness  in  Front. 


Fig.  166.     Method  of  Palpating  for  a  Mass  in  the  Kidney  Region.    The 
structures  are  caught  between  the  hand  behind  and  the  one  in  front. 


146 


GYNECOLOGIC  DIAGNOSIS 


kidney  or  suprarenal  capsule,  are  the  usual  causes  of  tenderness  in  the  left  upper 
abdomen.  Fig.  171  indicates  the  area  to  search  for  splenic  tenderness.  The 
dragging  pain  from  an  enlarged  spleen  is  usually  referred  by  the  patient  to 
about  this  area. 

Tenderness  in  Central  Upper  Abdomen  (Fig.  172). 

Tenderness  in  this  region  is  usually  due  to  an  affection  of  the  stomach  or  of  the 
liver.     Fig.  173  indicates  the  point  to  seek  for  stomach  tenderness,  and  Fig.  174 


i;    i 


Fig.  167.  The  Right  Upper  Abdomen.  The  site  of  the  gall- 
bladder, the  area  of  particular  interest  in  this  region,  is  indicated 
by  the  letters  G.  B. 


the  point  to  seek  for  tenderness  of  the  left  lobe  of  the  liver.  In  doubtful  cases, 
when  there  is  so  much  widespread  tenderness  that  there  is  uncertainty  as  to  whether 
it  is  from  the  stomach  or  the  liver,    remember  that  stomach  disease  is  often  ac- 


TENDERNESS  IN  CENTRAL  ABDOMEN 


147 


companied  by  attacks  of  pain  under  the  left  shoulder-blade  (usually  indicated  by 
the  patient  as  in  Fig.  175)  while  liver  disease  is  frequently  accompanied  l)y 
pain  under  the  right  shoulder-blade  (Fig.  176).  Less  freque.:tly,  tenderness 
■n  the  region  is  due  to  disease  of  the  pancreas  or  to  some  affection  of  the  peri- 
toneum. 

Tenderness  in  Umbilical  Region  (Fig.  177). 

Diseases  of  the  small  intestine  and  diseases  of  the  peritoneum  and  omentum, 
ire  the  usual  causes  of  tenderness   localized  in   this  resion.     In  the  lower  outer 


Fig.  168.  Indicating  the  site  for  Tenderness  or  a 
Mass  due  to  disease  of  the  Gall-bladder.  It  may  be 
found  anywhere  from  the  point  indicated  downward 
and  outward  to  the  margin  of  the  ribs  on  the  right 
side. 


Fig.   169.     Palpating  for  general  Tenderness  of  the 
Liver. 


portions  of  the  region  the  ureters  encroach,  and  may  cause  point  tenderness  on 
one  or  both  sides  (Figs.  154,  158).  Fig.  178  shows  palpation  for  tenderness  in 
the  umbilical  region. 


Diffuse  Tenderness   Throughout  Abdomen. 

The  usual  causes  of  this  are  general  peritonitis,  tubercular  peritonitis,  gastro- 
enteritis, neurasthenia  and  hysteria.  Appendicitis,  gastritis  and  many  other  con- 
ditions give  rise  to  tenderness  or  pain  which  is  diffuse  at  first,  but  it  soon  becomes 
distinctly  localized. 


148  GYNECOLOGIC  DIAGNOSIS 


MASS  FELT  OX  ABDOMINAL  PALPATION. 

The  masses  of  particular  interest  in  gynecologic  diagnosis  are  those  situated  in 
in  the  lower  abdomen.  For  exact  differential  diagnosis  these  are  preferably  taken 
up   later.     Consequently  here  I  shall  simply  indicate  by  name  the  various  masses 


Fig,  170.  The  Left  Upper  Abdomen.  The  site  of  the  spleen 
and  of  the  splenic  flexure  of  the  colon,  tiie  organs  in  this  region 
most  commonlj^  affected,  are  shown  by  the  stipling.  TMaen 
normal,  the  spleen  lies  considerably  higher  in  the  abdominal 
cavity  than  is  generally  supposed.  Its  anterior  projection  is 
shown  here  in  dotted  outline,  with  ^_he  lower  end  in  contact  with 
the  splenic  flexure  of  the  colon. 


found.  It  must  be  kept  in  mind,  however,  that  in  addition  to  the  various  masses 
that  may  originate  in  an}^  region,  masses  from  elsewhere  may  be  found  in 
that  region,  becau.se  of  growth  or  displacement  or  both.  In  Fig.  179,  the  ar- 
rows indicate  the  usual  direction  of  growth,  or  displacement,  of  a  tumor  of 
the  various  organs  outlined. 


MASS  FELT  IN  LOWER  ABDOMEN 


14!) 


Mass  Felt  in  Right  Lower  Abdomen  (Fig.  J 47). 

Tiil)al  Inflanmiation  (salpingitis,  pyosalpiiix,  ]iy<ln.salpiiix). 

Tubal  Pregnancy. 

Tubal  Tumor  (fibroma,  papilloma). 

Ovarian  Inflammation  (oophoritis,  ovarian  abscess,  cystic  ovary), 

Ovarian  Tumor  (cj-stic,  solid) . 

Parovarian  Tumor  (cystic). 


Fig.  171.  Indicating  the  area  to  search  for  Splenic  Tenderness 
or  Enlargement.  When  the  spleen  is  diseased  it  usually  becomes 
enlarged  and  heavy  and  sinks  below  the  margin  of  the  ribs  at  the 
point  indicated. 


Fibromyoma  of  Uterus. 
Appendiceal  Inflammation  or  Tumor. 
Tumor  of  Caecum. 
Movable  Kidney  or  Tumor  of  Kidney. 

iVlass  Felt  in  Left  Lower  Abdomen  (Fig.  156). 

Here  are  found  the  same  conditions  as  described  for  the  right  side,  substituting 
sigmoid  flexure  for  caecum  and  appendix. 


150 


GYNECOLOGIC  DIAGNOSIS 


Mass  Felt  in  Central  Lower  Abdomen  (Fig.  159), 

Pregnant  Uterus. 

Fibromyoma  of  Uterus. 

Malignant  Tumor  of  Uterus. 

Distended  Bladder  or  Tumor  of  Bladder. 

Pelvic  Inflammation  with  Exudate. 


Fig.  172.     The  Central    Upper  Abdomen.     Showiag   in  outline 
the  liver  and  stomach  and  pancreas. 


Pelvic  Tuberculosis.     • 

Tubal  Pregnancy. 

Ovarian  or  Broad  Ligament  Tumor,  growing  in  from  the  side. 

Appendiceal,  Caecal,  Sigmoid  or  Kidney  Mass,  extending  in  fi-om  the 
side. 

Occasionally,  Spleen,  Liver,  Gail-Bladder,  Stomach,  Pancreas  or  Per- 
itoneal Masses,  extend  into  this  region. 


THE  CENTRAL  UPPER  ABDOMEN 


.51 


Fig.   173.     Showing    the   region  for   Tenderness 
Mass  from  disease  of  the  Stomach  or  Pancreas. 


Fig.  174.     Showing  the  site  for  Tenderness  of  the 
Left  Lobe  of  the  Liver. 


Fig.  175.  The  gesture  of  the  patient  in  indicating  pain  Fig.  176.  The  gesture  of  the  patient  iu  indicating 
under  the  left  shoulder-blade— a  very  frequent  accom-  pain  under  the  right  shoulder-blade — a  verj'  frequent 
panLment  of  Stomach  Disease.  accompaniment  of  Liver  Dbease. 


152 


GYNECOLOGIC  DIAGNOSIS 


Mass   Felt  in  Right  Upper  Abdomen  (Fig.  167), 

Enlarged  Liver. 

Enlarged  Gall-bladder. 

Tumor  of  LiA^er. 

Abscess  of  Liver. 

Tumor  of  Pyloric  End  of  Stomach. 


~^ 


Fig.  177.     The  Central  Abdomen  or  Umbilical    Region,  showing 
in  outlipe  the  colon  and  small  intestine  and  omentum. 


Tumor  of  Duodenum. 

Tumor  of  Hepatic  Flexure  of  Colon. 

Tumor  of  Kidney. 

Abscess  of  Kidney. 

Tuberculosis  of  Kidney. 


MASS  IN   THE    UMBILICAL   REGION 


153 


Fig    178.     Palpating  for  Tenderness  or  a  Mass  in   the  Umbilical 
Region. 


l~P>^e^¥TZW7. 


Fig.  179.     Showing  the  Direction  of  Growth  of  Tumors  of  various  Abdominal  and  Pelvic  organs.     In  prac- 
t:cally  all  cases,  the  direction  of  enlargement  is  toward  the  umbilical  region.    (KeWy— Operative  Gynecology.) 


154 


GYNECOLOGIC  DIAGNOSIS 


Fig.    180.     Indicating    the   Area    of    Dullness    due    to 
moderate  Distention  of  the  Bladder. 

Mass  Felt  in  Left  Upper  Abdomen  (Fig.  170). 

Enlarged  Spleen. 
Tumor  of  Spleen. 
Abscess  of  Spleen. 


Fig.  181.  Indicating  the  .A.rea  of  Dullness  from  a  large 
Mass  of  regular  outline  springing  from  the  Center  of  the 
Pelvis,  for  example  tne  pregnant  uterus.  The  dotted 
line  shows  the  upper  limit  of  the  mass  as  determined 
by  palpation. 


MASS  FELT  IN  UPPER  ABDOMEN 

Tumor  of  Cardiac  End  of  Stomach. 
Tumor  of  Splenic  Flexure  of  Colon. 
Tumor  of  Kidney. 
Abscess  of  Kidne3\ 
Tuberculosis  of  Kidney. 


155 


Fig.  182.  Indicating  the  Area  of  Dullness  from  a  Cen- 
tral Pelvic  Mass  which  has  enlarged  to  such  an  extent 
that  it  nearly  fills  the  abdomen.  Notice  that  the  corona 
of  resonance,  surmounting  the  area  of  dullness,  is  sjin- 
metrical  on  the  two  sides.  If  the  mass  were  lateral,  for 
example,  an  ovarian  or  parovarian  tumor,  the  area  of 
resonance  would  be  decidedly  less  on  the  side  of  the  tumor 
than  on  the  opposite  side. 


Mass  Felt  in  Central  Upper  Abdomen  (Fig,  172), 


Tumor  of  Stomach. 

Tumor  of  Left  Lobe  of  Liver. 

Fecal  Impaction  in  Transverse  Coion. 

Tumor  of  Transverse  Colon. 

Tumor  of  Duodenum. 

Tumor  of  Pancreas. 


156 


GYNECOLOGIC  DIAGNOSIS 


AREA   OF  DULLNESS  IN  ABDOMEN. 

An  area  of  dullness  in  the  abdomen  indicates  that  something  solid  or  fluid  is  lying 
against  the  abdominal  wall,  pushing  the  intestines  away  or  flattening  out  the  intes- 
tine between  the  mass  and  the  wall.  When  an  area  of  dullness  is  found  in  percuss- 
ing over  the  abdomen,  the  first  thing  to  do  is  to  ascertain  its  exact  outline.  The 
getting  of  the  shape  of  the  area  clearly  in  mind  is  much  facilitated  by  outlining  it, 
wholly  or  partially,  with  a  lead  pencil  or  other  marker.  This  outlining  of  the  area 
shows  what  region  or  regions  it  is  situated  in,  and  also  shows  whether  or  not  it  is 
of  such  position  and  size  and  shape  as  would  be  likely  to  be  caused  by  the  en- 


Fig.  183.     Indicating  the  region  for  Dullness  from  ^ig   134      indicating  the  region  for  Dullness  from 

Enlarged  Liver.  Enlarged  Spleen. 


largement  of  any  adjacent  organ.  In  some  cases  the  employment  of  both  super- 
ficial and  deep  percussion  may  aid    some    in  differential  diagnosis. 

Then  determine  if  the  area  of  dullness  can  be  shifted  by  pressure — by  attempt- 
ing to  push  about  any  mass  that  may  be  in  the  abdomen. 

Then  determine  if  the  outUne  of  the  dullness  changes  with  the  position  of  the 
patient.  For  example,  mark  out  the  area  with  the  patient  lying  on  the  back,  then 
have  her  turn  on  one  side  and  mark  it  in  that  position.  Then  have  the  patient 
stand,  if  she  is  able,  and  mark  the  outline  of  the  dullness  in  that  position.  This 
is  of  much  importance  in  the  diagnosis  of  free  fluid  in  the  peritoneal  cavity. 

An  area  of  dullness  where  there  should  be  resonance  may  be  due  to  any  of 
the  following  conditions: — 

An  enlarged  organ — for  example,  the  bladder  distended  with  urine  (Fig.  180), 
a  pregnant  uterus  or  other  median  mass  (Figs.  ISl,  182),  the  liver  enlarged  from 
various  causes ''Fig.   183)    or  the  spleen  enlarged  from  various  causes  (Fig.  184). 


AREA  OF  DULLNESS  IN  ABDOMEN 


157 


The  dullness  extends  to  the  region  normally  occupied  by  the  organ.  It  has  about 
tiic  shape  to  be  expected  in  symmetrical  or  asymmetrical  enlargement  of  the 
organ  in  question.  There  are  other  evidences  of  disease  of  that  organ.  There  is 
nothing  else  found  to  account   for  the  dullness.     Each  of  these  points  should   be 


Fig.  185.      Showing  the  Area  of  Dullness  in  moderate 
Ascites,  with  the  patient  lying  on  her  back. 


considered  when  endeavoring  to  ascertain 
whether  or  not  a  mass  is  due  to  enlarge- 
ment of  some  particular  organ. 

Free  Fluid  in  Peritoneal  Cavity  (Acites). 
In  this  condition  the  fiuid  of  course  seeks 
the  lowest  part  of  the  peritoneal  cavity, 
being  drawn  there  by  gravity,  and  the 
upper  margin  of  the  fluid,  represented  by 
the  upper  margin  of  the  area  of  dullness, 
is  approximately  horizontal.  As  the 
patient  changes  position,  the  fluid  changes 
its  relative  position,  to  conform  to  the 
law  just  given  —  hence  the  change  in  the 
outline  of  the  area  of  dullness,  which  is 
so  characteristic  in  these  cases.  To  illus- 
trate the  application  of  this  law,  take  a 
case  of  moderate.ascites.  With  the  patient 
on  her  back  the  dullness  would  be  as  re- 


Fig.  186.  Showing  the  reason  for  the  disposition  of 
the  Dull  and  Resonant  Areas  ''n  a  case  of  moderate 
Ascites.      (Butler — Diagnostics  of  Internal  Medirine.) 


Fig.  187.  Indicating  the  relation  of  the  Dull  and 
Resonant  Areas  in  the  case  of  a  Tumor  occupying  the 
central  lower  abdomen.  (Butler — Diagnostics  of  In- 
ternal Medicine. ) 


Fig.  188.  Ascites.  Representing  the  patient 
turned  on  one  side.  The  fluid  gravitates  to  the 
underside,  leaving  the  upper  flank  resonant.  (But- 
ler—/^frt  (/hos/ics  of  Internal  Medicine.) 


158 


GYNECOLOGIC  DIAGNOSIS 


Fig.  189.     Indicating  the  Area  of  Dullness  in  a  case  of  moderate  Ascites,  w'th  the  patient 
turned  on  the  left  side. 


Fig.    190.       Indicating     the     Area    of   Dullness    in 
moderate  Ascites,  witli  the  patient  standing. 


presented  by  the  dark  area  in  Fig. 
185,  with  a  corona  of  resonance  about 
the  umbihcus,  which  is  the  highest 
point.  Fig.  186,  which  represents  a 
cross  section  of  the  body  in  such  a  case, 
explains  the  cause  of  the  dull  and  re- 
sonant areas.  Fig.  187  shows  the  con- 
trasting condition  produced  by  a  tumor, 
and  the  area  of  surface  dullness  pro- 
duced by  the  same  is  indicated  in  Fig. 
181.  When  the  patient  \\dth  ascites 
turns  on  her  side,  the  fluid  shifts  as 
indicated  in  Fig.  188  and  the  area  of 
dullness  changes  as  shown  in  Fig.  189, 
the  upper  flank  becoming  resonant. 
When  the  patient  stands,  the  fluid 
again  shifts,  seeking  the  lowest  part, 
and  the  outline  of  dullness  changes  to 
that  shown  in  Fig.  190.  Notice  that 
in  all  positions  of  the  patient,  the 
fluid  occupies  the  lowest  part   of  the 


DULLNESS  FROM  ASCITES 


159 


peritoneal  cavity,  and  the  upper  margin  of  the  fluid  is  approximately  horizontal. 
Of  course  the  height  of  the  area  of  dullness  varies  in  different  cases,  depending  on 
the  amount  of  fluid  in  the  cavity.  The  illustrations  already  referred  to  indicate 
the  dullness  in  the  cases  of  ascites  of  moderate  severity.  If  there  is  only  a  small 
amount  of  fluid  in  the  cavity,  there  may  be  only  a  small  area  of  dullness  appre- 
ciable in  each  flank,  as  the  patient  is  lying  on  her  back.  When  the  patient  turns  on 
the  side,  the  area  of  dullness  increases  appreciably  in  the  lower  side  and  disap- 
pears entirely  in-the  upper  flank.  When  the  patient  stands,  there  may  be  a  small 
area  of  dullness  in  lower  abdomen  just  above  the  pubes,  or  there  may  be  no  dull- 


Fig.   191.     A  case  of  Extreme  Ascites.     Same  patient  as  shown  in  Fig.  135.     Showing  the  Area  of  Dullness 
when  the  patient  is  on  her  Back.     The  light  area  is  all  that  is  resonant. 


ness  appreciable  anywhere  in  the  abdomen,  because  the  amount  of  fluid  is  so 
small  that  it  is  all  concealed  in  the  depth  of  the  pelvic  portion  of  the  peritoneal 
cavity.  On  the  other  hand,  in  exceptional  cases  the  amount  of  fluid  is  so  great 
that  it  fills  the  peritoneal  cavity  and  raises  the  abdominal  wall  above  the  intestines 
(higher  than  the  mesentery  will  permit  the  intestines  to  float),  giving  dullness 
about  the  umbilicus  as  well  as  elsewhere.  This  does  away  with  the  corona 
of  resonance  about  the  umbilicus,  which  is  so  characteristic  a  feature  of  ordinary 
ascites. 

Fig.  135  shows  a  patient  sent  to  me  with  a  supposed  ovarian  cyst.     The  general 


160 


GYNECOLOGIC  DIAGNOSIS 


appearance  was  very  much  like  that  of  a  cyst  distending  the  abdomen.  The 
area  about  the  umbilicus  was  dull,  excluding  ordinary  ascites.  "  In  percussing  care- 
fully over  the  whole  abdomen,  however,  I  found  an  area  of  resonance  in  the  left 
upper  abdomen.  Fig.  191  shows  the  outline  of  this  area  when  the  patient  was 
lying  on  her  back.  Fig.  192  shows  the  outline  of  the  area  of  resonance  when  the 
patient  was  standing.  A  comparison  of  these  two  areas  (Fig.  193)  showed  that 
there  was  decided  variation  in  the  area  of  dullness  with  the  change  of   position, 


Fig.  192.  Extreme  Ascites.  Area  of  Dullness  with  patient  Standing. 
Same  patient  as  shown  in  Fig.  191.  Notice  the  marked  change  in  the 
resonant  area.  The  upper  limit  of  the  dullness  is  now  almost  horizontal. 
The  former  marks  have  not  been  completely  removed. 


without  any  important  change  in  the  general  shape  of  the  abdomen,  a  condition 
that  could  be  caused  only  by  free  fluid  in  the  peritoneal  cavity.  As  the  patient 
stood,  there  was  distinct  bulging  of  the  umbilicus  (Fig.  138)  and  distinct  fluctua- 
tion through  the  thin  umbilicus.  There  was  present  also  edema  of  the  abdominal 
wall.  On  vaginal  examination,  no  tumor  was  felt  in  the  pelvis.  These  signs  were 
considered  sufficient  to  exclude  ovarian  cyst,  and  I  sent  the  patient  back  to  her 
physician  with  a  diagnosis  of  ascites.  As  there  was  no  decided  kidney  disease 
or  heart  lesion,  the   marked  ascites  was  supposed  to  l)e  of  hepatic  origin,  which 


CHANGEABLE  OUTLINE  OF  DULLNESS 


161 


diagnosis  was  confirmed  by  the  women's  death  from  sudden  gastric  hemorrhage 
and  by  the  partial  post-mortem  examination,  the  details  of  which  were  kindly 
given  me  by  her  physician. 

Figs.  136  and  137  show  other  cases  in  which  the  amount  of  ascitic  nuid  was  so 
great  that  the  abdominal  wall  was  raised  above  the  intestines,  and  the  corona  of 
resonance  about  the  umbilicus  was  consequently  absent. 


t 


/ 


/ 


Fig.  193.  Extreme  Ascites.  Same  patient  as  shown  in  Fig.  191.  The 
Two  Resonant  Areas  contrasted.  The  area  enclosed  by  the  sohd  hne  is 
resonant  when  the  patient  is  on  her  back,  while  all  elsewhere  is  dull  on 
percussion.  The  area  enclosed  by  the  dotted  line  is  resonant  when  the 
patient  stands,  while  all  elsewhere  is  dull.  The  change  of  outline  of 
the  dullness  on  change  of  posture,  is  clearly  marked. 


Again,  ascites  may  be  associated  with  an  abdominal  tumor,  either  as  a  complica- 
tion or  from  some  intercurrent  disease.  In  either  case,  the  association  of  the  two 
is  indicated  by  the  outline  of  the  area  of  dullness  with  the  patient  in  different 
positions.  Fig.  118  shows  a  patient  presenting  obesity  and  a  fibroid  tumor  and 
moderate  ascites.    The  obesity  was  very  apparent  on  inspection.     On  palpating,  to 


j^2 


GYNECOLOGIC  DIAGNOSIS 


determine  if  there  were  any  further  causes  for  the  prominent  abdomen,  I  found 
that  there  was  a  distinct  mass  extending  upward  from  the  pelvis  into  the  central 
abdomen.  Nothing  more  was  found  on  palpation,  except  considerable  tenderness 
over  the  tumor.  Passing  to  percussion  of  the  abdomen,  with  the  patient  lying  on 
her  back  there  was  dullness  over  the  mass  extending,  in  the  median  line,  to  a  short 
distance  above  the  umbilicus  and  extending  symmetrically  to  each  side.  In  trying 
to  determine  accurately  the  area  of  dullness  in  the  left  side,  I  found  that  it  extended 
horizontally  along  the  flank  as  shown  in  Fig.  194.  Percussion  in  the  right  flank 
showed  about  the  same  area  of  dullness  there.  The  patient  was  then  directed  to 
stand  and  percussion  was  again  employed.  When  standing,  the  area  of  dullness  was 
as  shown  in  Fig.  195.     A  comparison  of  these  two  outlines  (Fig.  196)  makes  it  plain 


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Fig.  194.  A  case  of  Ascites  and  Tumor.  Same  patient  as  shown  in 
Fig.  118.  Showing  the  Area  of  Dullness  with  patient  on  her  Back.  The 
central  dullness  is  caused  by  the  tumor  and  the  lateral  dullness  by  ascitic 
fluid.     The  dullness  is  practically  the  same  on  the  two  sides. 


that  there  was  an  unchanging  area  of  dullness  (due  to  the  tumor)  and  a  changing 
area  of  dullness,  due  to  free  fluid  in  the  peritoneal  cavity  (ascites) . 

Encysted  Fluid.  This  may  be  serum  or  ordinary  pus  or  tubercular  pus.  There 
is  dullness  over  the  mass  and  resonance  elsewhere  (Figs.  197,  198).  There  is  no 
change  in  the  outline  of  the  dullness  on  change  of  position  of  the  patient,  such  as 
occurs  with  free  fluid. 

A  rather  rare  condition  of  special  interest  coming  under  this  category  is  the 
pseudo-cyst- of  the' lesser  omental  cavity.  An  encysted  collection  of  fluid  occupy- 
ing the  cavity  occasionally  appears  several  weeks  or  months  following  an  abdom- 
inal injury.  Injuries  so  resulting  are  supposed  to  have  involved  the  pancreas,  it 
being  held  that  the  collection  of  fluid  in  the  lesser  omental  cavity  is  due  to  the  irri- 
tation from    pancreatic   fluid,  which    found    its  way  from  the  damaged  pancreas 


DULLNESS  FROM  ASCITES  WITH  TL'MOR 


163 


into  the  cavity  mentioned.  The  small  opening  that  leads  from  this  lesser  peri- 
toneal cavity  into  the  greater  pei'itoneal  cavity  (foramen  of  Winslow),  becomes 
closed  in  the  beginning  of  the  trouble  and  the  fluid  is  confined  within  the  lesser 
cavity.  As  this  cavity  lies  back  of  the  intestines,  the  mass  of  encysted  fluid  is 
partially  covered  l^y  intestinal  resonance,  presenting  the  characteristic  percussion 
signs  of  a  retro-intestinal  mass. 
Tumor  from  the  Pelvic  Organs.     The  tumor  may  be  solid  or  cy.stic.     It  may  be 


Fig.  195.  A.scites  and  Tumor.  Area  of  Dullness  with  patient  Stand- 
ing. Same  patient  as  shown  in  Fig.  194.  Notice  the  marked  change  in 
the  upper  limit  of  the  dullness.  It  is  now  almost  horizontal.  The  former 
marks  have  not  been   completely  removed. 


situated  in  the  center  or  laterally  or  may  fill  the  whole  abdomen.  There  is 
dullne.ss  over  that  portion  of  the  mass  lying  against  the  abdom.inal  wall  and  reson- 
ance elsewhere,  unless  there  is  associated  ascites.  There  is  no  decided  change  of 
outline  of  the  dullness  with  change  of  position  of  the  patient.  The  growth  may 
spring  from  the  uterus  (Fig.  199)  or  from  the  ovary  or  broad  ligament.  The 
latter  growths  are  usually  situated  well  to  one  side  at  first  but  later  may  fill 
the  whole  lower  abdomen.  Usually  in  such  a  growth  there  is  still  a  corona  of 
resonance  surrounding  the  upper  part  of  the  growth  and  extending  well  into  each 


164 


GYNECOLOGIC  DIAGNOSIS 


Fig.  196.  Ascites  and  Tumor.  Same  patient  as  shown  in  Fig.  194. 
The  Two  Areas  Contrasted.  The  solid  Hne  shows  the  border  of  the  dull 
area  when  the  patient  is  on  her  back  and  the  dotted  line  when  she  is 
standing.  The  change  of  outline  of  the  dullness  on  change  of  posture 
is  very  evident,  making  it  beyond  doubt  that,  whatever  other  abnormal 
condition  there  may  be  in  the  abdomen,  there  is  certainly  free  fluid 
Notice  also  that  as  the  patient  stands  the  upper  margin  of  the  dull  area 
(dotted  line)  is  approximately  horizontal. 


Fig.  197.  Indicating  the  situation  of  the  Area  of 
Dullness  due  to  a  large  Inflammatory  Mass  or  a  small 
Tumor    arising  from  the  right  Tubo-ovarian  region. 


Fig.  19S.  Indicating  the  situation  of  the  Area  of 
Dullness  due  to  an  Inflammatory  Mass  arising  from  the 
Appendix  or  Caecum. 


DULLNESS  I'HOM  AN  INTUAI'EUITUNEAL  MASS 


1G5 


flank.  In  other  cases  the  tumor 
grows  into  the  flank  and  crowds  the 
intestines  upward  and  into  the  oppo- 
site flank.  In  such  a  case  there  is 
dullness  over  all  the  front  of  the 
abdomen  and  also  in  one  flank,  there 
being  resonance  in  the  opposite  flank 
only  (Fig.  200).  Tliere  is  no  change 
of  the  outline  of  resonance  with 
change  of  position  of  the  patient, 
the  distinct  resonance  in  the  opposite 
flank  remaining  even  when  the  pa- 
tient is  turned  well  over  on  that 
side,  provided  there  is  no  compli- 
cating ascites. 

Tumor  from  some  abdominal  or= 
gan.  There  is  dullness  over  that 
portion    of   the  mass    lying  against 


Fig.  199.  Indicating  the  Irregularity  and  grutes- 
queness  of  form  often  presented  by  the  Dull  .\rea  in 
L'terine  Fibromyomata. 


Fig.  200.  Indicating  the  outline  of  the  Area  of  Dullness  in  a 
case  of  large  of  Ovarian  Cyst  from  the  right  side,  the  tumor  ha\-ing 
become  so  large  that  it  has  crowded  the  intestines  out  of  the  right 
flank,  and  its  dull  area  joins  with  that  of  the  liver.  The  left  flank 
is  resonant  and  remains  so  in  all  postures. 


the  wall  and  resonance  else- 
where, unless  there  is  asso- 
ciated ascites .  Such  a 
tumor  may  spring  from  the 
liver  or  from  the  spleen  oi 
from  some  part  of  the  gas- 
tro-intestinal  track.  The 
usual  sites  for  tumors  in 
the  digestive  track  are  the 
pyloric  end  of  the  stomach, 
the  caecum  and  the  sigmoid 
flexure  of  the  colon. 

Tumor  of  some  Retro- 
intestinal  Structure.  The 
characteristic  feature  of  re- 
troperitoneal masses  (either 
inflammatory  masses  or  nev' 
growths)  is  that  there  is  in- 
testinal resonance  in  front 
of  them.  When  the  growth 
reaches  a  large  size  the  in- 
testines are  usually  pushed 
aside  over  a  considerable 
area,  so  that  a  part  of  the 
palpable  tumor  mass  shows 
dullness   and  a  part   shows 


166 


GYXECOLOGIC  DIAGNOSIS 


Fig.  201.  The  Area  of  Dullness  in  a  Retroperitoneal  Growtli.  Same  patient  as  shown  in  Fig.  146. 
(Dr.  Elsworth  Smitli's  patient).  The  area  enclosed  by  the  solid  line  is  dull  on  percussion.  The  dotted  line  shows 
the  outline  of  the  growth  as  determined  by  palpation. 


Fig.   202.     Indicating   the  Area  of  Dullness  in  the  Fig.  20.3.    Indicating  the  Area  of  DuUness.in  the  case 

case  of  Kidney  Tumor,  before  inOation  of  the  colon.  ol  Kidney  Tumor,  after  inflation  of  the  colon. 


DULLNESS  FROM  A  RETROPERITONICAL  MASS 


167 


intestinal  resonance.  Fig.  201  sliows  such  an  abdominal  growtli.  The  size  of  the 
palpable  tumor  is  indicated  by  the  dotted  outline  and  the  area  of  dullness  is  sur- 
rounded by  the  solid  line.  Inflation  of  the  stomach  in  this  case  caused  the  area  of 
dullness  to  disappear  almost  entirely,  showing  that  the  growth  sprung  from  some 
structure  back  of  the  stomach  cavity.     A  retro-intestinal  tumor  may  spring  from 


Fig.  204.    The  Kidney  Tumor  itself  after  removal,  in  the  case  presenting 
the  signs  shown  in  Figs.  202  and  203. 


the  pancreas  or  from  the  mesenteric  glands  or  from  the  retro-peritoneal  glands 
or  adjacent  structures  or  from  the  kidneys  or  suprarenal  glands.  A  kidney 
tumor  not  infrequently  forms  a  large  mass  extending  from  the  lumbar  region  to- 
wards the  pelvis  and  the  median  line.  The  characteristic  percussion  sign  of  a 
kidney  growth,  or  other  retro-peritoneal  growth  in  that  region,  is  that   the  colon 


168 


GYNECOLOGIC   DIAGNOSIS 


resonance  can  be  made  out  in  front  of  it.  When  the  growth  is  large,  the  colon 
may  be  flattened  out  by  compression  between  the  tumor  and  the  abdominal  wall, 
a.nd  in  that  case  no  colon  resonance  would  be  obtained  in  the  ordinary  examina- 
tion. But  the  colon  resonance  can  be  easily  brought  out  by  inflation  of  the  colon 
with  air,  introduced  through  a  rectal  tube  by  means  of  the  ordinary  double-bulb  or 
an  atomizer  bulb.  This  point  is  well  illustrated  by  the  following  case.  Mrs.  M. 
was  sent  to  me  for  operation  for  a  fibroid  tumor  of  the  uterus.  There  was  a  large 
mass  Ijdng  in  the  left  lower  abdomen,  easily  palpable  and  extending  to  the  uterus. 
Superficially  it  prevented  the  appearance  of  a  pediculated  subperitoneal  fibroid. 
On  deep  palpation,  however,  this  prominent  mass  was  found  to  be  connected 
with  a  deeper  mass  which  extended  up  into  the   lumbar  region.      By  manipula- 


Descending  colon  . 


Prerenal  fascia  . 
Peritorieum  , 


RetrOrenal  fascia 


Small  intestine 

Superior  mesenteric 
artery 

Duodenum 


Ascending  colon 


Fig.  205.     A  case  of  Peri-renal  Lipoma — another  form  of  Retroperitoneal  Tumor.   (Edward  Reynolds — Aiuials  of 
Surgery.) 


tion  the  whole  mass  could  be  displaced  upward  somewhat,  sufficiently  to  show  that 
its  point  of  origin  was  probably  in  the  left  lumbar  region  and  not  in  the  pelvis. 
When  the  tumorwasdisplaced  upward,  the  vaginal  and  abdominal  fingers,  in  the 
vagino-abdominal  examination,  could  be  made  to  meet  between  the  mass  and  the 
uterus,  and  no  pedicle  connecting  the  two  could  be  felt.  The  diagnosis  then  lay 
between  a  kidney  tumor  and  an  enlarged  spleen.  The  palpable  portion  of  the 
mass  did  not  have  the  characteristic  shape  of  either  the  kidney  or  the  spleen, 
but  it  approached .  nearer  the  shape  of  the  spleen.  There  were  no  kidney 
symptoms.  Percussion  showed  dullness  all  over  the  mass  (Fig.  202)  —  there 
was  no  colon  resonance.  But  the  mass  was  more  deeply  placed  than  an  enlarged 
spleen  usually  is,  and  the  upper  end  seemed  to  extend  directly  into  the  kidney 
region.     So  I  inflated  the  colon  in  the  office  examination,  and  the  colon  resonance 


A  BILATERAL  KETKUi'ERlTUNEAL  TUMCJU 


169 


at  once  stood  out  well  on  percussion  (Fig.  203),  demonstrating  that  the  mass 
was  back  of  the  colon  and  therefore  probably  a  kidney  growth.  The  correctness 
of  the  diagnosis  was  proven  at  the  operation.  Fig.  204  shows  the  mass,  which 
was  a  cystic  tumor  of  the  kidney.  The  growth  was  so  large  that  it  was  neces- 
sary to  remove  it  by  transperitoneal  nephrectomy.     The  entire  absence  of  kidney 


Region   of  com. 
parative  safety. 


Fig.  206.  Peri-renal  Lipoma.  Same  case  as  Fig.  205.  A  view  from  in  front,  showing 
an  approximate  outline  of  the  tumor  and  the  possible  area  of  dullness,  and  also  how  the 
colon  could  be  made  to  stand  out  resonant  by  inflation.  Also,  the  "region  of  compara- 
tive safety"  for  beginning  enucleation  of  the  tumor,  is  indicated.  (Edward  RejTiolds— 
Annals  of  Surgery.) 


or  bladder  symptoms  was  due  to  the  fact  that  the  left  kidney  was  totally  destroyed 
and  had  not  been  secreting,  all  the  kidney  work  being  done  by  the  right  kidney. 
A  rare  and  interesting  form  of  retroperitoneal   growth  is   the   retroperitoneal 
lipoma,  which  usually  has  its  origin  in  the  peri-renal  fat. 


170 


GYNECOLOGIC  DIAGNOSIS 


It  may  grow  extensively  in  various  directions  and  in  some  cases  become  so  large 
that  it  fills  the  abdomen,  pushing  the  intestines  aside  or  flattening  them  out  on  its 
surface.  Edward  Reynolds,  of  Boston,  reported  a  very  extensive  tumor  of  this 
kind.  The  size  and  location  of  the  mass  and  the  area  of  percussion-dullness  are 
shown  by  Figs.  205  and  206,  which  are  from  his  article.  He  was  able  to  collect  forty- 
nine  cases  from  literature. 

Tumor  or  Inflammatory  Mass  in  Abdominal  Wall.  This  may  give  rise  to  dullness 
on  superficial  percussion  or  even  on  moderately  deep  percussion.  But  very  deep 
percussion  mil  show  some  resonance  ail  over,  except  in  cases  where  the  mass  is  so 
extremely  large  that  the  diagnosis  is  plain  from  other  signs.  Fig.  124  shows  a 
growth  situated  in  the  abdominal  wall. 


^  ^'xm^'5     § 


mmltk^-.  ^    -^'-"Iburc^tlfe 


ANUS 


DIAGRAM 


Fig.  207.  External  Genitals  of  a  Virgin.  Photo- 
graph from  a  cadaver.  (Dickinson — Am.  Text-book  of 
Obstetrics.) 


Fig  208.  Diagrammatic  representation  of  the 
External  Genitals  of  a  Virgin.  (Dickinson — Am. 
TeJct-book  of  Obstetrics.) 


POINTS  IN  THE  EXAMINATION  OF  EXTERNAL  GENITALS. 


The  appearance  of  the  external  genitals  in  the  virgin  are  slK)wn  in  Fig.  207. 
The  same  structures  are  shown  diagrammatically  and  witli  names  on  the  parts  in 
Fig.  208.     The  appearance  of  the  hymen  differs  much  in  different  ca.ses,  as  iudj- 


POINTS  CONCERNING  THE  EXTERNAL  CIENITALS 


171 


Fig.  209.     Showing  the  various  forms  of  Hymen.     (Dickinson — Am.  Text- Book  of  Obstetrics.) 


catecl  in  Fig.  209.  In  the  married  woman  the 
vaginal  opening  is  larger  and  dilatable  and  the 
labia  minora  are  better  marked,  being  usually 
much  larger  and  considerably  corrugated  (Fig. 
210).  When  the  patient  has  had  children;  the 
hymen  is  ordinarily  destroyed  and  the  vaginal 
Oldening  still  larger,  this  being  especially  notice- 
able after  the  labia  are  spread  apart  for  thf 
examination.  Fig.  211  shows  the  external 
genitals  in  such  a  case  before  the  labia  aie 
spread  apart.  Fig.  212  is  a  somewhat  closci' 
view  after  the  vulva  has  been  shaved,  as  in 
preparation  for  operation.  Fig.  213  shows 
the  labia  separated,  bringing  into  view  the 
vestibule,  meatus  and  vaginal  opening.  Fig. 
214  is  a  closer  view  with  the  operating  specu- 
lum in  place.  This  shows  exceptionally  well 
the  relation  of  the  urethral  opening  to  the 
vaginal  entrance  and  to  the  labia.  Very  often 
there  has  been  considerable  laceration  of  the 
perineum  without  any  particular  loss  of  sup- 
port in  the  pelvic  floor.  Fig.  215  shows  the  ap- 
pearance of  the  genitals  in  such  a  case. 


Fig.  210.      External  Genitals  u.  ^  .'.l„i. icd  Woman. 
(Dickinson— ^»'.  Text- Boole  of  Obstetrics.) 


172 


GYNECOLOGIC  DIAGNOSIS 


Fig.  21],     External  Genitals  of  a  Multipara,  with  the  labia  minora  not  yet  separated. 


APPEARANCE  OF  NORMAL  EXTERNAL  GENITALS 


173 


Fig.  212.     Same  patient  as  shown  in  Fig.  211,  with  the  genital  region  shaved  as  in  preparation  for  operation. 
This  gives  a  somewhat  closer  view  of  the  External  Genitals- 


174 


GYNECOLOGIC  DIAGNOSIS 


Fig.  213.      Same  as  Fig.  212,  with  the  labia  separated  to  sliow  the  "SVstibulc  and  Urethral  Opening  and  Va- 
gina) Opening. 


RELATIONS  OF  THE  MEATUS  URINARIUS 


175 


Fig.  214.  This  photopraph  was  taken  with  the  camera  very  close  to  the  patient  and  with  a  speculum  in  place 
as  for  operation.  The  Relations  of  the  Urinary  Meatus  and  the  Labia  Minora  and  the  Vaginal  Opening  are  well 
shown. 


176 


GYNECOLOGIC  DIAGNOSIS 


DISCHARGE  ABOUT  EXTERNAL  GENITALS. 

As  explained  in  chapter  i,  there  is  normally  a  slight  discharge  about  the  exter- 
nal genitals,  sufficient  to  keep  the  parts  moist. 

Abnormal  discharge  may  be  only  an  increase  in  the  normal  muco-epithehal  dis- 
charge or  it  may  be  muco-purulent  or  purulent  or  watery  or  bloody.  The  various 
kinds  of  discharge  are  conveniently  considered  under  the  two  terms,  leucorrhoea 
and  bloody  discharge. 

Leucorrhoea. 

Under  this  term  I  include  all  varieties 
of  pathological  discharge  from  the  geni- 
tals, except  discharge  containing  blood. 
Regarding  leucorrhoea  due  to  extra- 
genital disturbances  only,  that  is  hardly 
probable,  as  the  leucorrhoea  in  itself  is 
evidence  of  local  disturbance.  There 
are,  however,  certain  cases  in  which  the 
functional  ditsurbance,  evidenced  by 
the  leucorrhoea,  is  dependent  largely  on 
malnutrition  or  on  pelvic  congestion 
from  extra-genital  causes.  The  mild  leu- 
corrhoea found  in  the  anemic  or  cachetic, 
may  disappear  when  the  patient  is  put 
in  good  general  health.  Again,  in  pel- 
vic congestion  from  heart  disease  or 
from  some  general  cause,  there  may  be 
present  a  mild  leucorrhoea  which  dis- 
appears when  the  functional  pelvic 
congestion  is  corrected.  In  this  sense, 
leucorrhoea  may  be  said,  in  some  cases, 
to  be  due  to  extra-genital  causes  and  its 
relief  to  depend  on  treatment  of  the 
same.  In  all  but  exceptional  cases, 
however,  leucorrhoea  is  due  to  one  or 
more  of  the  following  local  conditions: 
Inflammation  or  Ulcer  of  Vulva,  There  is  a  history  of  discharge  from  the  vulva, 
of  burning  or  itching  and  of  freqeunt  urination  with  perhaps  some  pain.  Exami- 
nation of  the  external  genitals  shows  redness,  either  general  or  localized  to  certain 
areas.  There  is  tenderness  and  discharge  and  also  evidence  of  the  cause.  If  the 
trouble  is  an  ulcer^  it  may  be  simple,chancroidal,  syphilitic,  tubercular  or  malig- 
nant. Further  examination  shows  no  discharge  from  the  vagina  and  no  evidence 
of  trouble  there. 

Acute  Vaginitis.  There  is  a  history  of  a  free  yellow  discharge  of  short  duration, 
irritation  of  vulva  and  frequent  urination  with  some  burning.     Examination  shows 


Fig.  215.  External  Genitals  of  a  Multipara,  witli 
some  Perineal  Laceration.  (Dickinson — Am.  Text- 
Boole  of  Obstetrics.) 


SIGNU-'ICAXClv   Ob'   I.iacoKklloKA  177 

a  yellow  discharge  and  redness  of  vulva.  If  gonorrhoeal,  there  is  usually  involv- 
ment  of  vulvo-vaginal  glands,  also  the  discharge  shows  gonococci.  The  vagina! 
walls  are  rough  and  hot  and  tender — too  tender  to  admit  of  satisfactoiy  bimanual 
examination.  When  exposed  with  the  speculum,  the  vaginal  walls  are  reddened, 
and  there  is  not  enough  discharge  from  the  cervix  to  account  for  the  leucorrhoea. 

Chronic  Vaginitis.  This  occurs  principally  in  children.  There  has  been  a  yel- 
low discharge  for  several  weeks  or  months,  with  irritation  of  the  vulva  and  some 
bladder  irritability.  Examination  shows  a  yellow  discharge  and  some  rednes.s 
of  the  vulva,  with  more  or  less  tenderness.  The  discharge  should  be  examined  for 
gonococci.  If  the  patient  is  a  child,  no  vaginal  examination  is  made.  If  an  adult, 
examination  shows  tenderness  and  chronic  thickening  and  roughening  of  vaginal 
walls,  usually  most  marked  in  the  posterior  fornix.  Speculum  examination  shows 
redness  of  the  vaginal  walls,  either  generally  or  in  patches,  and  there  is  not  enough 
discharge  from  the  cervix  to  account  for  the  leucorrhoea. 

Adhesive  Vaginitis.  This  occurs  principally  near  or  after  the  menopause.  There 
is  a  histoiy  of  chronic  discharge,  with  irritation  of  the  vulva  and  sometimes  bladder 
irritability.  On  examination  it  is  found  in  most  cases  that  the  discharge  is  slight 
and  is  sticky  or  "gluey"  in  character,  though  in  exceptional  cases  it  is  free  and 
purulent.  In  some  cases  there  are  scratch  marks,  resulting  from  the  patient's 
attempts  to  overcome  the  pruritus.  On  vaginal  examination,  the  vaginal  walls 
are  found  adherent  in  spots,  especially  at  the  upper  part  of  the  vagina.  If  the  ad- 
hesions are  recent,  they  separate  easily  with  some  bleeding.  If  the  adhesions  are 
old,  they  are  firm  and  in  some  cases  the  vagina  is  almost  obliterated  by  the  process. 
When  the  walls  are  separated  with  the  speculum,  in  the  less  advanced  cases,  ir- 
regular spots  which  are  raw  and  bleed  slightly  may  be  seen. 

Ulcer  of  Vagina.  This  may  be  simple,  chancroidal,  syphilitic,  tubercular  or 
malignant.  There  is  a  history  of  an  acute  or  chronic  discharge,  and  probably  also 
of  other  evidences  of  the  disease  causing  the  ulceration.  Examination  shows  a 
discharge  about  the  vulva  and  more  or  less  irritation  of  the  surfaces.  When  mak- 
ing the  vaginal  examination,  the  indurated  edges  or  base  of  the  ulcer  may  be  felt. 
The  speculum  exposes  the  ulcer  to  view,  and  further  investigation  shows  it  to  be 
the  sufficient  cau.se  of  the  discharge. 

Acute  Endocervicitis.  There  is  a  history  of  a  tenacious,  stringy  discharge,  of 
recent  origin.  There  may  or  may  not  be  irritation  of  the  external  genitals.  Vag- 
inal and  bimanual  examination  show  nothing  special.  Speculum  examination 
shows  a  stringy  tenacious  discharge  coming  from  the  external  os.  There  is  also 
congestion  of  the  cervix  and  usually  erosion  about  the  external  os. 

Chronic  Endocervicitis.  There  has  been  a  discharge  for  a  long  time.  Vaginal 
and  bimanual  examination  show  no  evidence  of  involvement  of  the  corpus  uteri 
or  the  adnexa.  Speculum  examination  shows  a  very  tenacious,  string}^  muco- 
purulent discharge  from  the  external  os,  with  more  or  less  surrounding  erosion. 
In  many  cases  there  has  been  also  severe  laceration  of  the  cervix,  the  evidences 
of  which  may  be  felt  and  seen. 

Laceration  of  Cervix.  In  these  cases,  the  discharge  is  due  not  so  much  to  the 
tear  itseif  as  to  the  subsequent  e version  and  irritation  and  chronic  inflammation. 


178  GYNECOLOGIC  DIAGNOSIS 

The  various  appearances  presented  by  the  lacerated  cervix  are  shown  later  in  this 
cliapter,  under  "Points  in  the  Speculum  Examination." 

Ulcer  of  Cervix.  Such  an  ulcer  may  be  simple,  chancroidal,  syphilitic,  tuber- 
cular or  malignant.  There  is  a  history  of  leucorrhoea.  In  the  vaginal  exami- 
nation the  ulcer  of  the  cervix  may  or  may  not  be  felt,  depending  on  whether  or  not 
there  is  any  induration  in  the  edges  or  base.  When  the  cervix  is  exposed  with 
the  speculum,  the  ulcer  is  seen,  presenting  a  distinctly-marked  margin,  and  a  base 
of  granulation  tissue  (epithelial  covering  entirely  lost). 

Malignant  Disease  of  Cervix.  This  may  appear  in  the  form  of  an  ulcer,  with 
indurated  margins  and  base,  or  as  a  papillary  growth  from  some  spot  on  the  cervix 
or  within  the  cervix.  For  the  various  appearances  of  beginning  malignant  disease 
of  the  cervix,  see  under  "Points  in  the  Speculum  Examination"  in  the  latter 
part  of  this  chapter  and  see  also  chapter  ix. 

Polypi  of  Cervix.  Polypi  of  the  cervix,  of  various  kinds,  may  give  rise  to  con- 
siderable leucorrhoea,  though  usually  a  bloody  discharge  is  the  prominent  feature 
in  these  cases. 

Acute  Endometritis,  whether  gonorrhoeal  or  due  to  pus  infection  following  labor 
or  miscarriage,  gives  rise  to  free  discharge.  There  is  a  history  of  recent  labor  or 
miscarriage  or  instrumentation  or  gonorrhoea,  or  a  history  of  chronic  endometritis 
due  to  one  of  these  causes.  Examination  shows  a  free  discharge,  the  character  of 
which  points  to  the  cause  of  the  trouble,  as  explained  in  chapter  vi.  Vaginal  and 
bimanual  examination  show  tenderness  of  the  body  of  the  uterus,  but  no  tender- 
ness around  the  uterus,  unless  there  is  complicating  trouble.  Speculum  examination 
shows  a  free  purulent  or  sanguino-purulent  discharge  coming  from  the  uterus. 

Chronic  Endometritis.  There  is  a  history  of  chronic  leucorrhoea.  Examination 
shows  nothing  in  the  vagina  or  cervix  to  account  for  the  discharge.  The  body  of 
the  uterus  may  be  somewhat  enlarged  or  tender,  though  not  necessarily  so.  Through 
the  speculum,  it  is  seen  that  the  discharge  comes  from  the  uterus  and  not  from 
inflammation  of  the  vaginal  walls.  The  character  of  the  discharge  indicates  that 
it  comes  largely  from  the  endometrium  and  not  from  the  cervical  glands. 

Retro=displacement  of  Uterus  causes  leucorrhoea  by  causing  persistent  congestion 
of  the  endometrium,  resulting  in  a  chronic  endometritis. 

Fibroid  of  Uterus  causes  leucorrhoea  by  causing  chronic  irritation  of  the  endo- 
metrium, both  by  direct  pressure  and  by  interference  with  its  blood  supply. 

Cancer  of  Corpus  Uteri  causes  leucorrhoea  by  the  breaking-down  of  the  cancerous 
area,  and  also  by  the  chronic  irritation  of  the  adjacent  endometrium. 

Peri-uterine  Disease  causes  leucorrhoea  by  causing  chronic  congestion  of  the 
endometrium,  with  resulting  chronic  endometritis. 

Functional  Congestion  of  the  uterus  or  pelvis,  causes  leucorrhoea  by  causing  the 
nutritive  or  so-called  inflammatory  changes  in  the  endometrium  and  cervical 
mucosa. 

Bloody  Discharge  From  Genitals. 

Bleeding,  not  connected  with  menstruation,  may  vary  from  a  streak  of  blood,  or 
a  slight  coloring  of  a  muco-purulent  discharge,  to  a  free  flow  of  blood.    Occasionally 


SIGNIFICANCE  OF  BLOODY  DISCllAUGE  179 

there  is  a  hemorrha,2;e  sufficiently  free  to  threaten  the  patient's  life.  In  most  cases 
however  the  bloody  discharge  is  slight  and  irregular,  and  is  of  serious  import  only 
because  it  may  have  a  serious  condition  for  its  cause. 

Any  of  the  following  diseases  may  cause  a  bloody  discharge  from  the  genital 
tract,  the  character  of  the  discharge  varying  from  a  muco-purulent  discharge  only 
slightly  streaked  with  blood,  to  a  profuse  fiow  of  blood  and  clots. 

All  the  conditions  mentioned  in  the  first  part  of  the  list  give  rise  also  to  leucor- 
rhoea  and  are  mentioned  under  it  (pages  177,  178).  The  other  conditions  occur 
with  pregnancy  and  must  be  thought  of  whenever  a  bloody  discharge  is 
present. 

Inflammation  or  Ulcer  of  Vulva,  particularly  malignant  ulcer. 

Acute  Vaginitis. 

Chronic  Vaginitis. 

Adhesive  Vaginitis. 

Ulcer  of  Vagina. 

Acute   Endocervicitis. 

Chronic  Endocervicitis. 

Laceration  of  Cervix. 

Ulcer  of  Cervix. 

Cancer  of  Cervix. 

Polypi  of  Cervix. 

Acute  Endometritis. 

Chronic  Endometritis. 

Retro=displacement  of  Uterus. 

Fibroid  of  Uterus. 

Cancer  of  Corpus  Uteri. 

Perl=uterine  Disease. 

Functional   Congestion. 

Threatened  Miscarriage.  The  patient  may  have  m5=s«^d  the  menses  only  a  few 
days  or  she  may  be  several  months  pregnant.  Threatened  miscarriage  is  usually 
accompanied  by  considerable  pelvic  pain,  in  exceptional  cases  there  may  be 
bloody  discharge  for,  several  hours  or  a  day  or  two,  betore  pains  begin.  In  some 
cases  by  questioning  the  patient,  it  will  be  found  that,  failing  to  come  unwell  at 
the  proper  time,  she  has  been  taking  medicine  to  •'  bring  on  the  flow"  (produce  an 
abortion) . 

Miscarriage.  Here  there  are  sharp  cramp-like  pains,  with  the  expulsion  of  blood- 
clots  and  pieces  of  membrane  or  a  formed  fetus,  depending  on  the  period  of  preg- 
nancy at  which  the  accident  happens.  Then  the  pain  subsides  and  after  a  few  days 
the  bloody  discharge  ceases. 

Incomplete  Miscarriage.  The  uterus  is  not  entirely  emptied  and  the  retained 
remnants  cause  a  persistent  bloody  discharge  for  one  or  two  weeks  after  it  should 
have  stopped,  and  there  is  also  resulting  subinvolution  of  the  uterus.  The  blood 
may  pass  as  a  muco-sanguinous  discharge  or  in  clots.  It  may  disappear  when  the 
patient  stays  in  bed,  to  reappear  when  she  gets  up.  This  is  probably  the  most  fre- 
quent cause  of  persistent  bleeding  in  women  of  the  child  bearing  age.  There  is 
usually  little  pain  after  the  miscarriage  has  taken  place.     The  principal  symptom 


180 


GYNECOLOGIC  DIAGNOSIS 


is  the  bleeding,  with  the  resulting  anemia  and  weakness.  If  infection  takes-  place, 
the  symptoms  of  sepsis  are  added. 

Placenta  Praevia.  Bleeding  from  this  cause  does  not  usually  take  place  until  the 
pregnancy  has  advanced  so  far  that  the  diagnosis  is  perfectly  clear. 

Laceration  of  Cervix  with  Pregnancy.  The  cervix  is  lacerated  and  everted  and 
eroded,  and  there  is  added  the  softening  and  congestion  from  pregnancy.  There  are 
no  pains  such  as  accompany  miscarriage.  There  may  be  some  slight  pain  or 
uneasiness  in  pelvis,  which  is  relieved  by  lying  do'v\Ti.  The  bloody  discharge  per- 
sists, off  and  on,  without  apparent  evidence  of  threatened  miscarriage  or  other 
intra-uterine  disturbance. 

Tubal  Pregnancy.  The  rupture  of  a  tubal  pregnancy,  or  a  tubal  abortion,  is  nearlj'- 
always  followed  in  a  few  days  by  an  irregular  bloody  discharge,  which  may  persist 
for  several  days  or  several  weeks.  In  some  cases,  pieces  of  m-embrane  are  asso- 
ciated with  the  bloody  discharge.  There  are  also  the  other  evidences  of  tubal 
pregnancy  (see  chapter  xi). 


INFLAMMATION  OF  EXTERNAL  GENITALS. 

Inflammation  of  the  vulva  is  due  to  the  same  causes  as  inflammation  elsewhere, 
namely,  irritation  and  infection.     The  most  frequent  form  of  infection  here  is 

gonorrhoea,  although  other  varie- 
ties of  pus  infection  may  be  en- 
grafted on  wounds  or  abrasions. 
Qonorrhoeal  Vulvitis.  There  is 
a  free  yellow  discharge,  with  us- 
ually more  or  less  involvment  of 
the  urethra  and  also  of  the  ducts 
of  the  vulvo-vaginal  glands  (Fig. 
50).  There  is  no  cause  apparent 
for  the  persistence  of  a  simple 
inflammation.  Microscopic  ex- 
amination of  the  discharge  shows 
gonococci. 

Simple  Vulvitis.  Occurs  most 
frequently  in  children  and  is  due 
to  uncleanliness  of  the  parts  or  to 
an  irritating  vaginal  discharge  or 
to  irritating  urine  or  to  scratch- 
ing or  other  initation.  This  is 
not  usually  as  severe  as  gonor- 
rhoea! in.^lanniiation  and  sub- 
sides when  the  parts  are  cleansed 
frequently  and  protected  from 
irritation.  A  considerable  propor- 
tion of  the  cases  of  chronic  vulvi- 

Fig.  216.     Follicular  Vulvitis.     (A.Martin,  after  Iluguier  ,•        ■  i   -i  i  i  i 

-Atlas  of  aynecoiogy.)  tis   ui   children  are    gonorrhoeal. 


INFLAMMATION  OF  EXTERNAL  GENITALS 


LSI 


Fig.  21/.     Kraurosis  Vulvae.      (HiTst— Diseases  of  JFomen.) 


Consequently  the 
discharge  shoukl  l)e 
exaniinetl  to  deter- 
mine that  point. 

Follicular  Vulvi= 
tis  is  characterized 
by  the  inflamma- 
tion being  localized 
principally  in  the 
follicles  here  and 
there  (Fig.  216). 

Pruritis  Vulvae. 
Itching  of  the  geni- 
tals, from  varions 
causes,  leads  to 
scratching  and  con- 
sequent inflanmia- 
tion.  Usually  some 
cause  can  be  found 
for  the  itching.  If 
not,    the    affection    is,    for   the    time    being,    given    the    above    name. 

Kraurosis  Vulvae  (Fig.  217)  is  a  peculiar  neuro-atrophic  condition  of  the  external 
genitals,  usually  preceded  by  a  long  period  of  pruritis.  The  skin  becomes  atrophic 
and  has  a  bleached  and  draT\Ti  and  withered  appearance.  It  is  seen  most  frequently 
in  elderly  women,  and  is  usually  accompanied  by  intense  pruritis,  as  attested  by  the 

history  of  the  case  and   by   the    abra- 
sions from  scratching. 


ULCER  OX   EXTERNAL  GENI- 
TALS. 

Simple  Ulcer.  It  presents  none  ot 
the  characteristics  of  special  ulcers. 
There  is  some  source  of  irritation  suffi- 
cient to  account  for  the  ulcer  and  it 
heals  quickly  under  simple  cleansing 
treatment. 

Chancroidal  Ulcer  (soft  chancre). 
This  is  an  angr}-looking  sore  with  sharp- 
cut  or  undermined  edges.  It  is  pain- 
ful. The  margins  are  soft  unless  veiy 
old,  and  in  any  case  do  not  present  the 
extensive  and  firm  induration  found  in 
the  fully  developed  syphilitic  chancre. 
Usually  there  are  one  or  more  small 
sores  on  the  surfaces  that  come  in  con- 


c 


±-- 


ig) 


Fig.  218.    Chancroidal   Ulcers  of  the  vulva. 
Practice  of  Gynecology.) 


(Bovee- 


182 


GYNECOLOGIC  DIAGNOSIS 


tact  "^ith  the  secretion  from  the  first  sore  (Fig.  218).  There  may  be  a  history  of 
suspicious  coitus  a  few  days  previous  to  the  development  of  the  sore.  The  ulcer 
persists  in  spite  of  simple  antiseptic  remedies.  After  cauterization  with  carboHc 
acid,  it  presents  health}'  granulation  and  heals  rapidty. 

Syphilitic  Ulcer.     A  syphihtic  sore  appearing  about  the  external  genitals  ma; 
belong  to  the  primary,  secondary  or  tertiary  stage  of  the  disease. 

(a)  Primary  Syphilitic  Ulcer 
(hard  chancre)  .  This  appears  ten 
days  or  two  weeks  after  intercourse, 
but  may  be  preceded  by  a  simple 
sore  or  chancroidal  sore  (mixed  in- 
fection). It  is  not  painful  unless 
irritated  or  inflamed.  It  gradually 
enlarges  and  develops  a  distinct 
induration.  It  is,  a  little  later,  ac- 
companied by  enlargement  of  the 
inguinal  glands.  The  enlarged 
glands  are  painless,  discrete  and 
non-suppurating.  There  is  only  one 
such  sore.  It  is  followed  in  one  or 
two  months  by  the  secondary  mani- 
festations. 

(b)  Secondary  Syphilitic 
Ulcer.  These  are  usually  multiple 
and  very  supercial,  amounting  to 
little  more  than  abrasions.  They 
show  a  moist,  raw-looking  surface, 
or  are  slightly  raised  whitish  areas 
("mucous  patches").  They  are 
accompanied  by  one  or  more  of  the 
various  other  secondary  manifesta- 
tions of  syphilis,  the  most  common 
of  which  are  persistent  sore  throat, 
mucous  patches  in  the  mouth,  en- 
largement of  post-cervical  and  epi- 
trochlear  glands,  roseola  on  chest 
and  abdomen  and  loosening  of  the 
hair. 

(c)  Tertiary  Syphilitic  Ulcer. 
This  usually  has  deep  undermined  edges.  It  is  destructive  and  not  especially  pain- 
ful, and  is  accompanied  by  other  evidences  of  syphilis,  such  as  ulcer  of  rectum, 
gummata  along  tibia,  night  pains,  etc.  It  yields  to  anti-syphilitic  treatment,  pro- 
vided the  general  health  is  no  too  much  depressed. 

Tubercular  Ulcer  (Fig.  219).  This  is  a  chronic  ulcer  with  indurated  margins  and 
presenting  small  yellow  granules  in  the  base.  It  is  not  particularly  painful,  but  is 
persistent  in  spite  of  cleansing  treatment.  Microscopic  examination  of  an  excised 
piece,  shows  tuberculosis. 


Fig.  219.     A  Tubercular  Ulcer  of  the  vulva. 
Operative  Gynecology.) 


(Kelly- 


AN  ULOER  ON  EXTERNAL  CKNITVLS 


1.S3 


Malignant  Ulcer  (Figs.  220,  221,  222).  This  is  a  chronic  ulcer  with  a  consider- 
alile  area  of  iiuhiration  around  it.  It  ])Ieeds  easily,  and  the  bleeding  is  no  checked 
by  the  application  of  10  per  cent,  copper  sulphate  solution.  The  ulcer  persists  in 
spite  of  treatment.  Microscopic  exaniiiuition  of  an  excised  piece  shows  carcinoma 
or  sarcoma. 


Fig.  220.     An  Epithelioma  of  the  right  labium.     (Hiist 
— Diseases  of  Women.) 


Fig.  222.     .\n   Epithelioma   of    the   clitoris. 
Diseases  of  IFomen.) 


(Hirst- 


Fig.  221.  A  begimiing  Epithelioma  of 
the  left  labium  majus,  (Kelly— Operative 
Gynecology.) 

Ulcus    Rodens   Vulvae.      This   is 

chronic  and  is  irregular  in  shape, 
extending  in  various  directions  and 
healing  in  others,  and  resists  treat- 
ment. It  presents  none  of  the 
pathognomonic  signs  of  chancroidal, 
.•syphilitic,  tubercular  or  malignant 
ulcer.  The  essential  feature  of  ulcus 
rodens  vulvae  is  a  chronic  destruct- 
ive ulcer  of  the  vulva  that  can  not, 
properly  be  assigned  to  any  of  the 
other  classes. 


184 


GYNECOLOGIC  DIAGNOSIS 


MALFORMATIONS  OF  EXTERNAL  GENITALS. 
The  more  common  deviations    from  the  normal,  found    in  uninjured  genitaUa; 

are  as  follows:  (See  page  185) 


I 

A: 

%. 

I 

k.-  . 

j' 

Fig.  223.  A  case  of  Adherent  Prepuce,  the  clitoris 
being  entirely  hidden.  (Kelly — Operative  Gyneco- 
logy.) 


Fig.  224.  The  same  case,  with  the  Adhesions 
Separated  and  the  prepuce  pushed  bade  and  the  clitoris 
exposed.  Notice  the  smegma  concretions  which  had 
formed  under  the  adherent  prepuce.  (Kelly — Operative 
Gynecology.) 


Fig.  225.  The  Labia  Minora  Adherent  all 
along  their  free  margins.  (Kelly — Operative 
Gynecology.) 


Fig.  22o.  Inipcrloiate  ll\iiicii.  Jlicicis 
no  vaginal  opening,  the  urethra  being  the  only 
oi)ening  present  in  the  v es  tibule.  (Mont- 
gomery— Practical  Gynecology.) 


MALFORMATIONS  OF  P:XTERNAL  (iKNITALS 


185 


Preputial  Adhesions  (Figs.  223  and  224).  The  prominent  end  of  the  clitoris 
seems  to  be  absent.  Investigating  further,  to  see  just  what  is  the  trouble,  it  is 
found  that  the  folds  of  the  labia  minora,  which  encircle  the  clitoris,  are  agglutin- 
ated so  that  the  glans  clitoridis  is  partially  or  entirely  hidden. 

Labial  Adhesions.  The  labia  minora  may  be  adherent  partially  or  completely,  as 
shown  in  Fig.  225. 

Imperforate  Hymen.  There  is  no  opening  into  the  vagina  and  there  has  been 
no  menstrual  flow.  There  may  or  may  not  be  some  bulging  of  the  imperforate 
hymen.     If  there  is  much  blood  collected  back  of  the  obstruction,  fluctuation  may 

be  obtained.     Fig.   226  shows  the 
r  ,'|^4'3/^/,~V",  j    '  \Tl        appearance  of  the  vestibule  in  such 

a  case.  Figs.  227  and  228  give  a 
diagramatic  representation  of  the 
conditions  internally  in  different 
cases. 

Absence  of  Vagina.  Fig.  229 
shows  the  condition  of  the  external 
genitals  in  a  patient  with  no  vagina. 
Double  Vagina  (Figs.  230,  231). 
The  opening  of  the  second  vaginal 
canal  may  be  very  apparent  or  it 
may  be  hardly  noticeable  on  cur- 
sory inspection.  In  one  of  my  cases 
there  was  simply  an  unevenness, 
that  attracted  my  attention  almost 
by  accident.  Investigating  the  slight 
Fig.  227.    Hematocoipos,  which  may  result  from  im-       irregularity  at  the  side  of  thc'vagiual 

perforate  hymen  or  from  atresia  at  the  lower  portion  of 
the  vagina.  The  menstrual  blood  has  not  yet  distended 
the  uterus.     (Montgomery — Practical  Gynecology.) 


Fig.  228.  Imperforate  Hymen,  with  Uterus  and  Tubes 
distended  with  menstrual  blood.  (Ashton— Practice  o/ 
Gynecology.) 


Fig.  229.  The  appearance  of  the 
e.xternal  genitals  in  a  case  of  Absence  of 
the  Vagina.  (KeWy— Operative  Gyn3- 
cology.) 


186 


GYNECOLOGIC  DIAGNOSIS 


entrance,    I   found  a  slit-like  opening 
leading  into  a    second  vaginal  canal 
which  was  collapsed. 


.Si: ^Li_ 


SWJJ^rgfefeT. 


Fig.  230.  The  appearance  of  the  external 
genitals  in  a  ca.se  of  Double  Vagina.  (Kelly— 
Operative  Gynecology.) 


Fig.  231.  Same  case  as  Fig.  230,  ^-ith  Speculum  Intro- 
duced, exposing  the  two  vaginal  canals  and  the  half  cersix 
at  the  top  of  each.     (Kelly— Operative  Gynecology.) 


Fig.  232.  Complete  Laceration  of  the  Perineum.  The 
sphincter  ani  muscle  has  been  torn  and  the  ends  are  separa- 
ted. The  small  dark  area  is  an  exposed  portion  of  the  red 
mucosa  of  the  rectum.     (Himt'— Diseases  of  IFomen.) 


LACERATIONS  ABOUT  VULVA 
AND  PERINEUM. 

There  are  of  course  slight  lacera- 
tions of  the  hymen  in  normal  coitus, 
but  the  resulting  condition  belongs 
under  the  normal  appearances  of 
the  genitaha  (Fig.  210).  The  same 
may  be  said  of  the  usual  widening 
and  relaxation  of  the  vaginal  open- 
ing resulting  from  labor  (Fig,  213). 

Laceration  from  Labor.  Lacera- 
tion of  the  perineum  and  vagina 
in  labor  produces  changes  varying 
all  the  way  from  a  moderate  enlarge- 
ment of  the  vaginal  orifice  to  com- 
plete destruction  of  the  perineum, 
with  exposure  of  the  rectal  mucos.i 
and  incontinuence  of  feces. 

Fig.  215  shows  a  widening  of  the 
vaginal  opening,  due  to  a  moderate 
second  degree  tear  of  the  perineum. 
The  various  methods  of  testing  the 


LACERATION  OF  EXTERNAL  GENITALS 


187 


Fig.  233.  Another  case  of  Laceration  through  the  Perineum 
into  the  Rectum.  Notice  the  separation  of  tne  sphincter  ends 
and  also  the  patch  of  rectal  mucosa.  (Hirst — Diseases  of 
Women. ) 


Fig.  234.  Representation  of  the  conditions  present 
in  an  old  Laceration  through  the  Sphincter  Ani.  Notice 
the  wide  separation  of  the  sphincter  ends  and  al.so  the 
exposed  rectal  mucosa.  Each  end  of  the  torn  sphincter 
am  muscle,  is  indicated  by  a  slight  dimple  in  the  skin. 
(Kelly — Operative  Cunecology.) 


188 


GYNECOLOGIC   DIAGNOSIS 


Fig.  235.  The  scar  and  opening  resulting  frwn  a 
"Central  Tear"  of  the  perineum.  This  is  a  very  rare  con- 
dition. The  cliild  passed  out  througli  the  laceration-open- 
ing, situated  between  the  posterior  commissure  and  the 
rectum,  instead  of  through  the  vaginal  opening  proper. 
(Hart  and  Barbour — Manual  of  Gynecology.) 


Fig.  236.  Laceration  of  the  Hy- 
men from  Rape,  in  a  girl  aged 
twelve.  The  child  died  in  ten  days 
of  perironitis.  (Edgar — rractice  of 
Obstetrics.) 


Fig.  237.  Complete  Laceration 
of  the  Pelvic  Floor  in  an  infant  of 
eight  months,  from  Rape.  (Edgar 
—Practice  of  Obstetrics.) 


integrity  of  the  pelvic  floor  are  shown  in 
chapter  i.  Fig.  239  shows  a  severe  tear  of 
the  pelvic  floor,  with  resulting  relaxation 
and  loss  of  support. 

Figs.  232  and  233  show  complete  tears  of  the  perineum,  into  the  rectum.  The 
red  mucosa  from  within  the  rectum  shows  at  the  site  of  the  rectal  tear.  The  torn 
ends  of  the  sphincter  ani  produce  a  slight  dimple  in  the  surface  covering  them 
(Fig.  234). 

Fig.  235  shows  a  central  tear  of  the  perineum,  a  very  unusual  form  to  result  from 
child-birth. 

Lacerations  from  Other  Causes.  Fig.  236  shows  a  laceration  of  the  hymen  from 
forcible  coitus  (rape)  in  a  girl  aged  twelve.  There  were  also  deeper  injuries,,  caus- 
ing peritonitis,  from  which  she  died  in  ten  days.     Fig.  237  shows  a  tear  from  the 


SWELLING  ABOUT  EXTERNAL  GENITALS 


18ft 


same  cause  involving  the  perineum  in  an  infant.     Fig.  2.3S  shows  a  deep  tear  of 
the  perineum,  causing  a  recto-perineal  fistula,  from  violent  coitus. 


Fig.  238.     Laceration   of    Perineum   with   re.sulting  Fistula,  from 
Violent  Coitus.     (KiTst— Diseases  of  Women.) 

SWELLING  ABOUT  EXTERNAL  GENITALS. 
Colpocele,  Cystocele,  Rectocele.     These  swelhngs  appear  as  the  result  of  lacera- 
tions.    Fig.  239  shows  a  severe  second  degree  tear,  involving  practically  all  the 


Fig.  239.     An  old  Laceration   from   Labor.     Most   of   the  perineum   has  been  torn  and    there    is 
protrusion  of  the  posterior  vaginal  wall  (posterior  colpocele).     (Baldy— ^m.  _  Text-hook  of  Gynerology.) 


190 


GYNECOLOGIC  DIAGNOSIS 


perineum  down  to  the  sphincter  ani  muscle,  and  also  a  posterior  colpocele.  Pigs.  240 
and  241  show  such  a  laceration  with  the  anterior  and  posterior  vaginal  walls  begin- 
nings to  protrude,  and  there  is  also  protrusion  of  the  bladder  and  rectum  (cystocele 
and  rectocele).  In  such  a  condition,  if  the  patient  be  directed  to  bear  down,  the 
protrusion  will  become  still  more  marked.  Fig.  242  shows  marked  protrusion  of 
the  anterior  vaginal  wall  accompanied  by  the  base  of  the  bladder  (cystocele). 

The  fact  that  the  bladder  wall  is  prolapsed  along  with  the  vaginal  wall,  is  indi- 
cated by  the  fact  that  the  patient  has  more  or  less  difficulty  in  urinating,  and  in 

some  cases  she  must  push  back  the 
mass  before  she  can  urinate  satisfactorily. 
When  there  is    doubt  as  to  whether  the 


Fig.  240.     Cystocele  and   Rectocele  of  moderate  ex-  Fig.  241.     Cystocele  and  Rectocele  of  moderate  ex.' 

tent.      (Thomas  and  'Munde— Diseases  of  Women.)  tent.     Sectional  view.      (Thomas  and  Munde — Diseases 

of  Women.) 


bladder  wall  comes  down,  the  lowest  part  of  the  bladder  cavity  may  be  located 
with   a  steel   bougie  (Fig.  243). 

Fig.  244  shows  slight  rectocele  (protrusion  of  the  posterior  vaginal  wall  accom- 
panied by  the  anterior  rectal  wall).  Fig.  245  shows  a  large  rectocele.  The  point 
as  to  whether  or  not  the  rectal  wall  really  follows  the  prolapsed  vaginal  wall,  may 
be  settled  in  such  a  case  by  rectal  examination  (Figs.  246,  247). 

inflammation  of  Vulva  (erysipelas,  cellulitis).  There  are  the  usual  signs  and 
symptoms  of  acute  infiainmation.  Owing  to  the  large  amount  of  loose  cellular 
tissue,  the  inflammatory  infiltration  may  cause  very  marked  swelling. 

Hematoma  of  Vulva.  There  is  rapid  swelling  foliowing  a  puncture  Avith  a  hypo- 
dermic needle  or  a  fall  or  other  injury.  There  is  marked  enlargement,  painful  on 
pressure  and  presenting  in  a  short  time  discoloration  from  blood  pigment.     There 


DIAGNOSIS  OF  CYSTOCELE 


idJ 


is  no  fever  nor  erysipelatous  redness  nor  other  evidence  of  acute  inflammation. 
Fig.  248  shows  a  hematoma  of  the  vulva. 

Edema  of  Vulva  (from  heart  or  liver  disease  or  from  pressure  by  a  pelvic  tumor). 
This  produces  a  boggy,  painless  swelling  which  pits  on  pressure.  There  is  no 
evidence  of  acute  inflammation  or  of  hematoma.     There  may  be  accompanying 


Fig.  242.     Large  Cystocele.     (Montgomery— Practical  Gyneculvrju.) 


edema  of  the  abdominal  wall  and  lower  extremities.  There  is  found  some  internal 
trouble  to  account  for  the  edema  (heart  disease  with  failing  circulation,  tumor  or 
inflammatory  mass  obstructing  the  pelvic  circulation). 

Stasis  Hypertrophy  of  Vulva.  There  is  a  gradual  development  of  tissue  hyper- 
trophy, with  more  or  less  inflammatory  infiltration.  The  swelling  is  not  partic- 
ularly painful  and  there  is  no  decided  pitting  on  pressure.     It  is  accompanied  by 


192 


GYNECOLOGIC    DIAGNOSIS 


Fig.  243.  Testing  for  Cystocele  with 
Sound  introduced  into  bladder.  (Ash- 
ton — Practice  of  Gynecology.) 


Fig.  244.    Small  Rectocele.     (Hirst— Disease*  of  fFomen.) 


DIAGNOSIS  OF  REOTOCELE 


193 


Fig.  245,     Large  Rectocele.     {Kiist— Diseases  of  Women.) 


Figs.  246  and  247.  Method  of  Differentiating  between  Rectocele  and  Posterior  Ccipocele. 
The  index  finger  in  the  rectum  determines  whether  or  not  the  rectal  wall  follows  the  prolapsing 
vaginal  wall.  The  hand  should  be  gloved.  Fig.  246,  Rectocele.  Fig.  247.  No  Rectocele. 
(^Aahton— Practice  of  Gynecology.) 


I6J4 


GYNECOLOGIC   DIAGNOSIS 


Fig.  248,     Hematoma  of  the  Vulva.     (Hirst— /diseases  of  Women.) 


Fig.  249.     Stasis  Hypertropliy  of  the  Labia  Minora.     (Hirst- 
Diseases  of  Women.) 


STASIS  HYPERTROPHY  OF  VULVA 


195 


scar-tissue,  resulting  from  chronic  ulceration,  of  such  extent  anri  so  situated  at  the 
vaginal  entrance  as  to  obstruct  the  lymph  and  blood  circulation  'Figs.  249  250 
251,  252,  253). 


Fig.  250.     Stasis  Hypertrophy  of  the  Vulva.      (Hirst— X>ise«ses  of 
Women.) 


Fig.  251.     Stasis  Hypertrophy  of  the  Vulva.     {HiTst— Diseases  of  Wo^.fa->. 


196 


GYNECOLOGIC    DIAGNOSIS 


Fig.  252.  Stasis  Hypertrophy  about  external 
genitals  and  edema  from  pregnancy.  (Dickinson 
—American  Text-book  Obstetrics.) 


Fig.  254  shows  the  scar  tissue  about  the 
bony  arch,  distorting  the  tissues  and  inter- 
fering with  the  return  flow  of  blood  and 
iymph. 

Another  cause  of  stasis  hypertrophy,  is 
the  infiltration  and  hypertrophy  due  to  the 
lymph  vessels  being  choked  with  a  parasite, 
the  filaria  sanguinis  hominis.  This  is  seen 
almost    exclusively   in    tropical    countries. 

Elephantiasis  of  Vulva.     The  term   "ele- 


Fig.  253.  So-called  Elephantiasis 
— probably  stasis  hypertrophy.  (By- 
ford,  after  Winkel — Manual  of  Gyne- 
cology.) 


Fig.  254.  Stasis  Hypertrophy  of  Vulva,  with  en- 
larged parts  raised  so  as  to  show  the  ulceration  and 
scar  tissue  about  the  pubic  arch.  (K\\ia.r\\— Surgical 
Diagnosis.) 


Fig.  255.  Elepnaiitiasisof  the 
Labia.  (V>-jiidy—Am,erirn,i  Te.rt- 
book  of  (rynecology.) 


SIMPLE  CONDYLOMATA  OF  VULVA 


197 


phantiasis''  is  very  appropriately  applied  to  the  cases  of  enormous  labial  hyper- 
trophy, such  as  shown  in  Fig.  255.  The  stasis  hypertrophy  previously  described, 
is  often  spoken  of  as  "elephantiasis,"  but  I  think  it  not  advisable  to  use  the  term 
so  loosely   (see  chapter  iv). 


Fig  256.     Varicose  Veins  of  the  Vulva.     (Hirst— Diseases  of  Women.) 


Fig.  257      Scattered  Condylomata  of  the  Vulva.     ( Hirst- Z>iseases  of  ffomen.) 


198 


GYNECOLOGIC    DIAGNOSIS 


Varicose  Veins  of  Vulva. 

These  not  infrequently 
cause  marked  swelling,  as 
shown  in  Fig.  256.  Seri- 
ous enlargement  of  the 
veins  is  found  most  fre- 
quently in  pregnancy  or  in 
the  case  of  some  pelvic 
tumor  or  inflammatory  mass 
obstructing  the  pelvic  cir- 
culation. Alarming  hem- 
orrhage has  followed  the 
rupture  of  ah  enlarged  vein 
in  such  cases. 

Condylomata  of  Vulva. 
From  Chronic  Irritation. 
As  a  result  of  persistent  irri- 
tation and  discharge  about 
the  vulva,  small  papillary 
masses  grow  from  the  skin  at  various  points  (Fig.  257).  They  may  come  from 
any  persistent  irritation,  though  chronic  gonorrhoea  is  the  most  frequent  cause. 
Sometimes  they  appear  in  great  profusion  (Fig.  258)  and  occasionally  they  coalesce 
and  form  large  papillary  masses  (Figs.  259,  260) .  These  papillary  growths  are 
called  pointed  condylomata,  in  contra- 
distinction to  the  fiat  condylomata  which 
are  usually  due  to  syphilis. 

From  Syphilis     In  secondary  syphilis, 
white  areas    with  infiltration  sufficient, 


Fig.  258.     Small   Masses   of   Condylomata. 
Gynecology .) 


(Gilliam — Practical 


Fig.   259.     Condylomata   forming    large   Masses. 
(Pozzi — Treatise  on  Gynecology.) 


Fig.  260.  The  whole  vulgar  region 
occupied  by  Massed  Condylomata. 
(Kustner— A'M?-ces  Lehrhuch  dcr  (lyna- 
Icologie.) 


SYPHILITIC  CONDYLOMATA  OF  VULVA 


199 


to    raise    them    above    the  surface,   often    appear   about    the  external  genitals. 
They  may  be  few  or  many  (Figs.  261,  262),  and  they  may  be  raised  much  or  little. 


Fig.  261.     Syphilitic  Infiltration  and  Condylomata   about  the  vulva. 
(Hirst — Diseases  of  Women.) 


Fig.    262.      Syphilitic    Condylomata.       Flat    variety. 
(Bovfee — Practice  of  Gynecology.) 


200 


GYNECOLOGIC  DIAGNOSIS 


They  are  usually  flat  condylomata,  only  rarely  being  pointed  or  papillary 
(Fig.  263). 

Vulvo-vaginal  Gland  Cyst  or  Abscess.  The  swelling  has  much  the  same  appear- 
ance whether  it  be  a  cyst  or  an  abscess.  Figs.  264  and  265  show  abscesses  of  the 
gland.     Fig.  266  shows  a  cyst  of  the  gland. 

Hypertrophy  of  Labia.  The  hypertrophies  affect  principally  the  labia  minora, 
either  the  free  portion  on  one  or  both  sides  (Fig,  267)  or  that  portion  extending  up 
over  the  clitoris  as  the  prepuce.     The  hypertrophied  portions  contain  much  re- 


b'ig.  263.    Syphilitic  Condylomata.    Pointed  variety.     (Hirst — 
Diseases  of  Women). 


dundant  tissue  and  are  corrugated  and  usually  somewhat  pigmented.  In  some 
cases  the  hypertrophy  becomes  very  marked,  as  in  the  Hottentot  apron,  shown  in 
Fig.  268. 

Hypertrophy  of  CUtoris.  This  is  much  rarer  than  hypertrophy  of  labia.  Occa- 
sionally the  clitoris  is  considerably  enlarged.     Fig.  269  shows  such  case. 

Malignant  Disease  of  Labia  or  Clitoris.  Malignant  disease  (carcinoma  or  sar- 
coma) appears  upon  the  lal)ia  as  a  small  reddened  nodule,  which  later  ulcerates. 


ABSCESS  OF  VULVO-VAGINAL  GLAND 


201 


Fig.  221  shows  a  beginning  carcinoma  of  left  labium  majus.  Fig.  270  shows  a 
small  carcinoma  of  labium  minus.  Figs.  271  and  272  show  carcinoma  of  the  labium 
at  a  later  stage.  Fig.  273  shows  an  advanced  carcinoma  of  the  vulvo-vaginal  gland. 
Fig.  274  shows  a  sarcoma  of  the  labium.     Fig.  222  shows  a  carcinoma  of  clitoris. 

Non-malignant  Tumor  of  Labia  or  Clitoris.  Fibromata  and  lipomata  and  cysts 
occur  here,  though  not  very  frequently.  Fig.  275  shows  a  small  fibroma  of  the  left 
labium    majus.     Fig.  276  shows  a   larger  solid  tumor  of   the  labium.     Fig.  277 


Fig.  264.     Abscess  of  Vulvo-vaginal  Gland,  left  side.     (Kelly— Opera- 
tive Gynecology.) 


shows  a  number  of  small  cysts  on  the  labium.  Figs.  278  and  279  show  large  labial 
cysts.     Fig.  280  shows  a  cyst  of  the  clitoris. 

Pudendal  Hernia.  A  hernia  of  intestine  or  omentum  or  other  mtraperitoneai 
structure,  may  take  place  through  the  inguinal  canal  and  appear  in  the  labmm 
majusof  that  side  (Fig.  281).  •       /x^- 

Another  form  of  pudendal  hernia  is  that  which  comes  by  way  of  the  vagina  (tig. 


202 


GYNECOLOGIC    DIAGNOSIS 


Fig.  265.    Another  case  of  Abscess  of  Vulvo-vaginal  Gland,  right  side.      (Hirst — Diseases 
of  IFomen.) 


-pm^^:-^=^^^^^^'-^^-^y---  ^^ 


Fig.  266.  Cyst  of  the  Vulvo-vaginal 
Gland.  (Montgomery — Practical  GynS' 
cology.) 


HYPERTROPHY  OF  LABIA  MINORA 


203 


Fig.  267.     Hypertrophy  of  the  Labia  Minora.     {Hiist— Diseases  of  Women.) 


Fig.  268.  Enormous  Hypertrophy  of  the  Labia  Minora— the  so-called  "Hottentot  Apron."  The  first  cut  shows 
the  patient  standing,  with  the  hypertrophied  labia  hanging  between  the  thighs.  The  second  cut  shows  the  patient 
on  her  back,  with  the  labia  separated.    (Garrigues,  after  Z'weiiel— Diseases  of  Women.) 


204 


GYNECOLOGIC    DIAGNOSIS 


Fig.  269.     Hypertrophy  of  the  Clitoris.      (Hirst— X>iseases  of  Wmnen.') 


Fig.  270.     Carcinoma  of  Labium  Minus,  beginning.     (Hirst— Z>iseases  o/ 
Women.) 


CARCINOMA  OF  LABIUM 


205 


Fig.  271„     Carcinoma  of  Labium   at  a  larger  stage. 
(Hirst — Diseases  of  Women.) 


I 


<*    .,^ 


Fig.  272.     Carcinoma  of  Labium  in  a  still  later  stage.      (Hirst— Z>i8eo«es 
of  Women.") 


206 


GYNECOLOGIC  DIAGNOSIS 


Fig.  273.     A  large  Carcinoma  of  the  left  Vulvo-vaginal  Gland.     (Kelly- 
Operative  Gynecology.) 


FIBROMA  OF  LABIUM 


207 


Fig-  274.     Sarcoma  of  Labium.      (Hirst— /diseases  of  Women.) 


Fig.  276.  A  large  Fibroma  of  the 
Labium.  (Montgomery— Pwc^'cni  ai/ne- 
cology.) 


Fig.  275.  A  small  Fibroma  of  lert  Labium 
«ajus.  {^aXAy— American  Text-hook  of  Gyne- 
eoloaii.) 


2D8 


GYNECOLOGIC     DIAGNOSIS 


Fig.  277.     Small  Cysts   of  the  Left  Labium  Minus. 
(Kelly — Operative  Gynecology.) 


Fig.  278.     A  large  Labial  Cyst.      (Uirst— Diseases  of  Wome7i.) 


CYSTS  OF  VULVA 


209 


Fig.  279.      Another  large  Labia!  Cyst.      (Hirst— /diseases  of  Women.) 


Fig.  280.     A  Cyst  of  the  Clitoris.      (Kelly— Operative 
Gynecology.) 


21C 


GYNECOLOGIC    DIAGNOSIS 


Fig.  281.     An  Inguinal  Hernia   becoming 
Pudendal.   (Dudley — Practice  of  Gynecology.) 


282),  the  protrusion  taking  place  in  front  of 
the  uterus  in  some  cases  (Fig.  327)  and  be- 
hind the  uterus  in  others. 

Pudendal  Hydrocele.  A  collection  of  fluid 
occasionally  occurs  in  the  canal  of  Nuck, 
forming  a  hydrocele,  which  corresponds  to 
hydrocele  of  the  cord  in  the  male. 

Tumor  of  Round  Ligament.  Fibromyoma 
of  the  round  ligament  is  a  rare  condition 
and  one  that  causes  much  distortion  of  the 
structures  about  the  inguinal  canal,  conse- 
quently it  is  likely  to  lead  to  an  erroneous 
diagnosis.  It  should  be  considered  when- 
ever there  is  a  peculiar  swelling  in  the 
neighborhood  of  the  inguinal  canal. 

Prolapse  of  the  Urethral  Mucosa  (Fig. 
283).  This  occurs  to  a  slight  extent  in 
many  women  who  have  borne  children  or 
have  had  inflammation  of  the  urethra.  Not 
infrequently  the  protrustion  is  marked  and  no  doubt  leads  in  many  cases  to  an 
erroneous  diagnosis  of  caruncle.  The  prolapsed  mucosa  encircles  a  considerable 
part  of  the  circumference  of  the  meatus,  and  a  close  inspection  will  show  that  the 
small  mass  presents  the  smooth, though  irregular,  surface  of  hypertrophied  mucosa, 
instead  of  the  papillary  projections  usually  present  in  urethral  caruncle.  Again, 
the  meatus  is  much  widened  from  the  previous  injury  or  inflammation,  and  the  pro- 
lapsing of  the  mu- 
cosa may  bring  into 
view  the  orifice  of  the 
duct,  or  Skene's  gland, 
on  one  or  both  sides 
(Fig.  48). 

Urethral  Caruncle 
(Fig.  284).  This  is  a 
distinct  new  growth, 
usually  papillary  in 
form,  springing  from 
the  region  of  the  mea- 
tus. It  may  have  a 
narrow  pedicle  or  a 
broad  attachment,  but 
does  not  tend  to  en- 
circle the  meatus  as 
does  prolapsed  nui- 
cosa. 


Fig.  282.     A  Pudendal   Hernia   which  came  by  way  of  the  Vagina. 
Macnaughton-Jones,  after  Winokel— /diseases  of  Women.) 


(H. 


PROLAPSED  URETHRAL  MUCOSA  AND  CARUNCLIO 


211 


Malignant  Disease  of  Urethra.  This  starts  usually  in  some  small  spot  of  irrita- 
tion about  the  meatus,  and  in  the  early  stage  presents  a  small  ulcer  or  induration. 
Later  the  infiltration  involves  the  vestibule,  urethra  and  adjacent  tissues. 

Suburethral  Abscess.  This  consists  of  a  pouch  formed  by  a  diverticulum  from 
the  urethra,  usually  from  the  inferior  wall.  Inflammation  and  suppuration  take 
place  in  this  pouch,  which  may  or  may  not  drain  irregularly  into  the  urethra. 
When  distended,  it  may  project  at  the  vaginal  orifice  (Fig.  285)  like  a  small  cyst  of 
the  anterior  vaginal  wall.     Fig.  286  gives  a  clear  idea  of  the  condition. 


it&/ 


Fig.  283.     Prolapse  of  the  Urethral   Mucosa. 
(Montgomery — Practical  Gynecology.) 


Fig.   284.       Urethral   Caruncle.      (Montgomery- 
Practical  Gynecology.) 


Prolapse  of  Uterus  (Fig.  287).  When  the  uterus  prolapses  sufficiently,  the  firm 
cervix,  with  the  external  os  near  the  center,  appears  at  the  vestibule  (Fig.  288). or  it 
may  come  farther  out,  as  shown  in  Fig.  289,  or  it  may  come  still  farther,  so  that 
the  entire  uterus  is  outside  the  body  (Fig.  290) . 

The  bladder  may  or  may  not  prolapse  along  with  the  uterus.  Fig.  291  represents 
a  case  in  which  the  bladder  does  not  prolapse.  Fig.  292  represents  a  case  in  which 
the  bladder  does  come  down  with  the  displaced  uterus.  The  method  of  locating 
the  bladder  by  the  introduction  of  a  sound,  is  shown  in  Fig.  293.     Ulcers  of  various 


212 


GYNECOLOGIC    DIAGNOSIS 


Fig.  285.     Suburethral  Abscess.     View  from  in    front. 
(Kelly — Operative  Gynecology.) 


SUBURETHRAL  ABSCESS 


213 


Fig.  286.    Testing  for  Suburethral  Abscess.     (Ashton— 
Practice  of  Gynecology.) 


Fig.  287.     Prolapse  of  the  Uterus,  showing  the  various 
steps  in  the  process.      (KeWy— Operative  Gynecology.) 


214 


GYNECOLOGIC  DIAGNOSIS 


Fig.  288.     A  case  of  Prolapse  of  the  Uterus.     The  cervix  is  at  the  ve^-dbule.     (Hirst — 
Diseases  of  Women.) 


PROLAPSE  OF  THE  UTERUS 


215 


Fig.  289.     Another  case  of  Prolapse  of  the  Uterus.     The  uterus 
comes  still  farther  out. 


216 


GYNECOLOGIC  DIAGNOSIS 


Fig.  290.  Another  case  of  Prolapse  of  the  Uterus.  The  uterus 
and  vagina  lie  outside  the  body.  The  ulceration,  so  frequent  in 
these  cases,  is  very  e\'ident,     (Hirst — Diseases  of  Women.) 


Fit;.  291.  Prolapse  of  the  Uterus.  Sectional  view 
The  bladder  remains  in  place.  (Kelly — Operative 
Gynecology.) 


PROLAPSE  OF  BLADDER,  WITH  UTERUS 


217 


Fig.  292.      Prolapse  of  the  Uterus  and  Bladder.      (Doderlein  and  Kronig— Operative  Gynakologie.) 


Fig.  293.  Testing  for  Prolapse  of  the 
Bladder  with  the  uterus,  by  means  of  a 
sound  in  the  bladder.  (Ashton— Practice 
of  Gynecology.) 


218 


GYNECOLOGIC   DIAGNOSIS 


sizes  and  shapes,  may  appear  on  the  exposed  irritated  surfaces.  Such  ulceration  is 
shown  in  Fig.  290.  Prolapse  may  occur  in  a  woman  who  has  never  had  a  child 
(Fig.  294)  or  even  in  the  virgin  (Fig.  295).  The  position  of  the  fundus  is  made  out 
by  recto-abdominal  palpation,  as  indicated  in  Fig.  296. 


Fig.  294.    Prolapse  of  the  Uterus  in  a  Nullipara.     (Hirst — Diseases  of  IVomen.) 


Fig.  295.     Prolapse  of  the  Uterus  in  a  Virgin. 
(Kustner — Kurzes  Lehrhuch  der  Gynalcologie.) 


HYPERTROPHY  OF  THE  CERVIX  UTERI 


219 


Elongation  of  the  Cervix  produces  a  condition  which  is  not  infrequently  mistaken 
for  prolapse.  If  the  hypertrophy  affects  only  the  infra-vaginal  portion  of  the  cer- 
vix(Fig.  297-a)the  vaginal  walls  are  not  carried  downbut  remain  in  normal  position, 
producing  the  condition  shown  in  Figs.  298  and  299.  When  the  elongation  affects  the 
supra-vaginal  portion(Fig.  297-c),  both  vaginal  walls  are  carried  down  with  the  pro- 


Fig.  296.    Locating  the  body  of  the  Uterus  by  recto  -abdominal  palpation, 
in  a  case  of  suspected  Prolapse.      (Ashton — Practice  of  Gynecology.) 


trading  cervix,  producing  a  condition  (Fig.  300)  very  likely  to  be  mistaken  for 
uterine  prolapse,  unless  the  depth  of  the  uterine  cavity  be  measured  or  the  body  of 
the  uterus  be  carefully  outlined  by  bimanual  palpation.  In  these  cases  the  drag- 
ging of  the  relaxed  and  redundant  vaginal  walls,  seems  to  be  an  important  factor  in 
producing  the  elongation  of  the  cervix. 
When  the   hypertrophy  or  stretching,   as  the 

case  may  be,  affects 
the  intermediate  por- 
tion of  the  cervix 
(Figs.  297-b),  the  an- 
terior vaginal  wall  is 
usually  carried  down 
while  the  p  o  s  te  r  i  o  r 
wall  remains  in  place 
(Fig.  301).  The  time- 
honored  division  of  the 
cervix  into  three  por- 
tions, as  indicated  in 
Fig.  297,  is  convenient 
for  fixing  in  mind  the 
conditions  ordinarily 
present  in  these  cases, 


Fig.  297.  The  Three 
Divisions  of  the  Cervix : 
(a)  Infra-vaginal  Portion. 
(6)  Intermediate  Portion, 
(c)  Supra- vaginal  Portion. 
(Byford — Manual  of  Gyne- 
cology.) 


Fig.  298.  HjTDertrophy  of  the  Infra- 
vaginal  Portion  of  the  Cerv'ix.  (Byford — ■ 
Manual  of  Gynecology .) 


220 


GYNECOLOGIC  DIAGNOSIS 


Fig.  299.     Hypertrophy  of  the  Infra-vaginal  Portion 
of  the  Cervix.      (Kelly — Operative  Gynecology.) 


but  it  must  be  remembered  that  in 
many  cases  the  vaginal  wall  does 
not  run  very  much  further  up  on  the 


1 

1 

•JnP 

I 

^i^^^M 

4- 

f^ 

1 

1 

i 

Fig.  300.  Hypertrophy  of  the  Supra- 
vaginal Portion  of  the  Cervix,  carrying 
down  the  vagina  and  cervix  to  the 
vulva.  The  uterine  cavity  in  this  case 
measures  five  and  a  half  inches.  An  area 
of  erosion  is  present  on  the  posterior 
lip  of  the  cervix.  {GUliam— Practical 
Gynecology.) 


Fig.  301.  Hypertrophy  of  the  Inter- 
mediate Portion  of  the  Cervix,  carrying 
down  the  anterior  vaginal  wall  and  bladder 
but  not  the  posterior  vaginal  wall.  (By- 
ford  —Manual  of  Gynecology.) 


Fig.[302.  A  specimen  presentinc  a  pcciiliar  HjTjer- 
trophy  of  the  Cervix.  The  posterior  vaginal,  wall  is 
carried  down  but  not  the  anterior.  (Herman— 
Diseases  of  Women.) 


DIAGNOSIS  OF  CERVICAL  HYPERTROl'HV 


221 


posterior  part  of  the  cervix  than  it  does  on  the  anterior  and,  consequently,  elon- 
gation of  the  middle  or  intermediate  portion  of  the  cervix  does  not  always  carry 
down  the  anterior  vaginal  wall  and  leave  the  posterior  in  place — in  fact,  in  the 
case  shown  in  Fig.  302,  it  has  carried  down  the  posterior  wall  and  left  the  anterior. 
The  differentiation  from  prolapse  of  the  uterus  is  made  l:)y  locating  the  fundus 
uteri  at   about  the  normal  position  in  the  pelvis,  by  vagino-abdominal  or  recto- 


Fig.  303.     Pediculated  Fibroid  Tumor  of  the  Uterus, 
protruding  at  the  vulva.    (Kelly— Operative  Gynecology.) 


abdominal  palpation,  and,  if  necessary,  by  sounding  the  uterus  to  determine  the 
length  of  the  uterine  cavity.  In  elongation,  the  cavity  is  increased  in  length  suf- 
ficiently to  account  for  the  appearance  of  the  cervix  at  the  vulva.  In  prolapse  of 
the  uterus,  there  is  usually  some  elongation  of  the  supravaginal  portion  of  the  cervix 
by  the  dragging  of  the  prolapsing  vaginal  walls,  but  it  is  of  secondary  importance. 


222 


GYNECOLOGIC    DIAGNOSIS 


Fig.  304.  Complete  Jiivei&ionof  the  Uterus,  forming  a  large  mass  at 
the  vulva.  This  is  a  post  partum  inversina  and  the  placenta  is  still 
attached  to  the  turned-out  fundus  uteri.     (Williams— Obstetrics.) 


Fig.  305.     A  small  Cyst  of  the  Vaginal  Wall.     (Uirat— Diseases  of  Women.) 


CYSTS  OF  THE  VAGINAL  WALL 


22:i 


In  the  cases  in  which  the  elongation  of  the  cervix  is  the  principal  lesion,  there  is 
usually  some  prolapse  of  the  uterus,  due  to  the  dragging  of  the  heavy  cervix. 

Tumor  of  Uterus.  A  mass  appearing  at  the  vulva,  may  be  a  pediculated  fibroid 
(Fig.  303)  or  a  malignant  tumor  from  the  uterus. 

Inversion  of  Uterus  (Fig.  304).     This  rare  condition  may  produce  an  appearance 


Fig.   306.      A    medium-sized  Vaginal  Cyst,  caught  with  a   forceps   and 
brought  into  view.      (WiTst— Diseases  of  Women.) 


very  closely  resembling  a  necrotic,  bleeding  tumor  protruding  from  the  vulva. 
The  internal  conditions  are  shown  in  Fig.  312. 

Vaginal  Cyst.  This  may  be  confounded  with  cystocele  or  vaginal  hernia  or  sub- 
urethral abscess.  The  differential  diagnosistic  points  are  the  absence  of  inflamma- 
tion, the  distinct  fluctuation,  the  tenseness  of  the  sac  containing  the  fluid  and  its 
attachment  to  some  part  of  the  vagina.     Figs.  305  and  306  show  such  vaginal  cysts. 


224  GYNECOLOGIC   DIAGNOSIS 

POINTS  IN  THE  VAGINAL  EXAMINATION. 

ROUGHENING  OF  VAGINAL  WALLS. 

Astringent  Douche.  Any  astringent  douche,  for  example,  one  coniaining  alum 
or  bichlorid,  will  cause  temporary  roughening  of  the  vaginal  wall.  But  there  is  no 
particular  tenderness. 

Inflammation.  It  is  found  in  acute  vaginitis,  simple  or  gonorrhoeal,  and  in  some 
cases  of  chronic  vaginitis.  In  addition  to  the  rough  granular  feel,  there  is  tender- 
ness of  the  wall,  and  the  speculum  examination  shows  reddening 

TENDERNESS  ON  VAGINAL  PALPATION. 

Inflammation  of  Vaginal  Entrance.  The  tenderness  is  noticed  as  soon  as  the  ex- 
amining finger  begins  to  enter  the  vagina.  There  may  be  diffuse  redness  of  the  sur- 
face around  the  vaginal  orifice  or  there  may  be  simply  reddened  areas  that  are  ten- 
der on  pressure  or  there  may  be  abrasions  or  slight  fissures  or  there  may  be  one  or 
more  distinct  ulcers. 

Inflammation  of  Vulvo-vaginal  Gland  or  Duct.  There  is  swelling  and  tenderness 
at  the  site  of  the  gland  and  redness  about  the  duct,  and  in  some  cases  pus  may  be 
squeezed  from  the  duct. 

Hyperesthesia  of  Vaginal  Entrance.  There  is  great  exaggeration  of  the  reflex  sen- 
sibility of  the  tissues  immediately  about  the  vaginal  orifice,  and  yet  no  evidence  of 
inflammation  or  fissure  or  ulcer  or  other  adequate  cause  for  pain.  In  some  cases  the 
reflex  excitability  is  so  great,  that  contact  causes  spasm  of  the  levator  ani  and  asso- 
ciated muscles  to  such  an  extent  as  to  prevent  the  examination.  This  uncontrol- 
lable spasmodic  closure  of  the  vaginal  orifice  is  known  as  "  vaginisimus. " 

Inflammation  of  Vagina.  There  is  purulent  discharge  and  the  vaginal  walls  are 
rough  and  hot.  Speculum  examination  shows  marked  reddening  of  the  walls 
(arterial  congestion)  and  also  discharge  upon  them. 

Inflammation  of  Urethra.  The  tenderness  is  along  the  lower  part  of  the  anterior 
vaginal  wall  and  is  complained  of  when  pressure  is  made  along  the  course  of  the 
urethra.  There  may  be  distinct  thickening  about  the  urethra,  which  may  be  felt 
as  a  firm  cord  beneath  the  public  arch.  In  most  cases  there  is  redness  about  the 
meatus,  and  some  discharge  may  be  pressed  out  by  compressing  the  urethra  from 
above  downward  (Figs.  46,  47). 

Inflammation  or  Other  Painful  Affection  of  the  Bladder.  Pain  is  caused  b}^  pres- 
sure upward  along  the  middle  of  the  anterior  vaginal  wall,  which  lies  against  the 
base  of  the  bladder.  There  are  also  the  symptoms  of  bladder  irritation  (frequent 
urination,  painful  urination),  and  also  the  findings  on  urinary  analysis. 

Inflammation  or  Other  Painful  Affection  of  the  Rectum.  Pain  is  caused  by  pres- 
sure backward  along  the  posterior  vaginal  wall  (Fig.  60).  There  is  also  evidence 
of  rectal  irritability  (pain  on  defecation,  rectal  tenesmus),  and  possibly  the  passage 
of  blood  or  mucus. 

Inflammation  Around  Uterus  ''cellulitis,  salpingitis,  pelvic  peritonitis).     Pain  is 


POINTS  IN   THE  VAGINAL  EXA.MINAITON  225 

caused  by  pressure  on  the  vaginal  wall  around  the  uterus,  either  in  front  of  the  cer- 
vix or  behind  it  or  at  one  side.  Pain  is  caused  also  by  any  attempt  to  move  the 
uterus,  as  by  pushing  on  the  cervix. 


MASS  FELT  IN  VAGINAL  PALPATION. 

Prolapsed  Vaginal  Wall  (colpocele).  The  vaginal  wall  is  more  redundant  than 
it  ought  to  be  and  part  of  it  descends  toward  the  opening.  It  may  be  the  anterior 
vaginal  wall  (anterior  colpocele)  or  the  posterior  vaginal  wall  (posterior  colpocele) 
(Fig.  239)  or  both.  The  mass  presents  the  characteristics  of  relaxed  vaginal  wall. 
There  is  no  distinct  firm  body  in  it. 

Prolapse  of  Bladder  (cystocele).  In  some  cases  of  prolapse  of  the  anterior  vaginal 
wall,  the  bladder  follows  the  vaginal  wall  (Fig.  241).  This  is  known  as  cystocele, 
as  previously  explained.  The  bladder  wall  is  soft  and  therefore  can  not  be  felt  dis- 
tinctly in  the  mass,  as  the  uterus  can.  It  is  noticed,  however,  that  there  is  much 
more  soft  tissue  in  the  mass  than  would  be  furnished  by  the  prolapsed  vaginal  wall 
and,  as  the  bladder  lies  next  to  the  vagina,  it  is  to  be  assumed  that  this  extra  tissue 
is  bladder  wall.  Sometimes  there  is  enough  urine  in  the  prolapsed  pouch  of  bladder 
to  give  fluctuation.  Usually  there  is  some  bladder  irritability  (frequent,  painful 
urination),  and  in  some  cases  the  patient  has  found  that  she  must  push  back  the 
mass  each  time  before  she  can  urinate  satisfactorily.  If  there  is  still  doubt  as  to 
whether  or  not  the  bladder  descends  with  the  vaginal  wall,  and  it  is  important  to 
know  certainly,  introduce  a  steel  urethral  bougie  (about  No.  20F)  and  see  if  the  tip 
passes  easily  into  the  mass  (Fig.  243). 

Prolapse  of  Anterior  Wall  of  Rectum  (rectocele) .  The  anterior  wall  of  the  rectum 
may  follow  the  posterior  vaginal  wall  in  its  descent  through  the  vaginal  orifice 
(Figs.  244,  245).  A  digital  examination  per  rectum  will  quickly  show  whether  or 
not  the  cavity  of  the  rectum  extends  into  the  mass  (Figs.  246,  247). 

Prolapse  of  Uterus  (Fig.  287).  The  cervix  is  felt  much  lower  (closer  to  the  va- 
ginal entrance)  than  normal,  or  it  may  present  at  the  vaginal  orifice  or  even  project 
far  outside  (Fig.  289).  Bimanual  examination  shows  that  the  body  of  the  uterus 
also  is  lower  than  usual  (Fig.  296),  and  consequently  that  the  condition  is  prolapse 
of  the  uterus  and  not  simply  elongation  of  the  cervix. 

Elongation  of  Cervix.  The  cervix  is  felt  much  lower  than  it  ought  to  be.  Bi- 
manual examination  shows  that  the  body  of  the  uterus  is  in  normal  position.  If 
the  bimanual  examination  does  not  make  plain  the  length  and  position  of  the  body 
of  the  uterus,  the  uterus  may  be  sounded.  This  will  show  that  the  length  of  the 
uterus  is  sufficient  to  account  for  the  low  position  of  the  cervix.  In  some  cases  the 
two  conditions,  prolapse  of  the  uterus  and  elongation  of  the  cervix,  are  both  present. 

Tumor  of  Uterus.  There  is  a  solid  or  semi-solid  mass  lying  in  the  vagina  (Figs. 
307,  308,  309,  310,  311).  The  finger  may  be  passed  all  around,  between  the  mass 
and  the  vaginal  wall.  When  the  finger  is  passed  around  the  mass,  its  connection 
with  the  cervix  is  felt.  It  may  spring  from  a  portion  of  the  cervix  within  reach,  or 
it  may  be  connected  with  a  pedicle  extending  up  into  the  canal. 

Inversion  of  Uterus  (Fig.  312).     There  is  a  mass  the  size  of  the  uterus  lying  in  the 


226 


GYNECOLOGIC  DIAGNOSIS 


Fig.    307.      A  small    Pediculated  Fibroid  of  Uterus,  projecting 
into  the  vagina.     (Montgomery — Practical  Gynecology.) 


Fig.  308.  A  large  Pediculated  Uterine 
Fibroid  lying  in  the  vagina.  (Thomas  and 
.\Iunde — Diseases  of  Women.) 


Fig.  309.  \  Pediculated  Fibroid,  with  the  sound  in 
place  to  differentiate  it  from  inversion  of  the  uterus. 
(Dudley — Practice  of  Gynecology.) 


A  MASS  FEI/r  IN  THE  VAOINA 


227 


Fig.  310.  A  Sarcoma  of  the  Uterus  projecting  into  the 
vagina  and  causing  partial  inversion  of  the  uterus. 
(Kelly — Operative  Gynecology.) 


311.  Grape-like  Sarcoma  springing  from 
the  Cervix  uteri  and  forming  a  mass  in  the 
vagina.  (Kustner— A'Mr~e«  Lehrbnch  der 
Gynakologie.) 


"m 


GYNECOLOGIC  DIAGNOSIS 


vagina,  having  a  raw  looking  mucous  surface  exposed.  Palpation  of  the  upper  part 
of  the  mass  shows  that  it  is  connected  with  the  cervix  by  a  broad  pedicle,  and  the 
dilated  cervical  ring  may  be  felt  around  it.  Figs.  313  to  321  give  a  clear  idea  of 
inversion  and  conditions  that  may  be  confounded  with  it. 


Fig.  312.     Inversion  of  the  Uterus,  forming  a  mass  in  the 
vagina.      (Kelly— Operotire  Gynecology.) 


Fig.  313.    Begining  Inver- 
sion of  the  Uterus. 


Fig.  314.  Submucous  Fib- 
roid with  short  pedicle. 


Fig.  315.  Submucous  Fib- 
roid and  beginning  Inver- 
sion. 


DIAGNOSIS  OF  INVERSION  OK  UTKHUS 


229 


Fig.  316.      Partial    Inver 
sion  of  Uterus. 


Fig.  317.   Submucous  Fib- 
roid with  long  pedicle. 


Fig.  3 18.   Pediculated  Fib- 
roid and  partial    Inversion. 


Fig.  319.      Complete   In- 
version of  Uterus. 


Fig.  320.  Pediculated  Fib- 
roid filling  upper  part  of 
vagina. 


Fig.  321.  Complete  Inver- 
sion of  Uterus,  with  a  pedi- 
culated subperitoneal  Fib- 
roid occupying  the  normal 
site  of  the  uterus. 


Figs.  3 13  to  321.  Inversion  of  the  Uterus  and  Conditions  that  Simui>ate  it.  (Dudley— Practice  of  Gynecology.) 


Fig.  322.  F'S-  323. 

Diagnosis  of  Inversion  of  the  Utercs. 
Fig.  322  shows  the  method  of  determining  the  absence  of  tlie  body  of  the  uterus  froia  the  pelvic 
cavity.    Fig.  323  shows  the  determination   of  the  presence  of  a  cup-shaped  depression  above  the 
cervix.      (Ashton— Practice  of  Gynecology.) 


230 


GYNECOLOGIC  DIAGNOSIS 


Bimanual  examination  (under  anesthesia,  if  necessary)  shows  the  body  of  the 
uterus  absent  from  where  it  should  be  (Fig.  322),  and  instead  there  is  a  cup  like  depres- 
sion above  the  cervical  ring  (Fig.  323).  Also,  a  sound  will  not  pass  up  into  the 
uterine  cavity  but  is  stopped  on  all  sides  a  short  distance  within  the  cervical  open 
ing  (Fig.  324) .     There  may  be  inversion  associated  with  a  tumor  (Fig.  325) . 


Fig.  324.  Differential  Diagnosis  of 
Inversion  by  means  of  the  sound. 
On  all  sides  the  sound  is  stopped  a 
short  distance  within  the  cervix. 
(Ashton — Practice  of  Gynecology.) 


Fig.  326.     A  group   of  small    Cysts  of  the  Vaginal 
Wall.     (Montgomery — Practical  Gynecology.) 


Fig.  325.  A  Pediculated  Fibroid  Causing 
Inversion  of  the  Uterus.  This  shows  also  a 
danger  to  be  avoided  in  treatment.  Ampu- 
tation of  the  fibroid  by  cutting  across  the 
pedicle  at  the  level  of  the  line  A,  B,  would 
open  the  peritoneal  cavity.  (Thomas  and 
Munde — Diseases  of  IFomen,) 


Fig.  327.    Anterior  Vaginal  Hernia.    (Ashton 
-Practice  of  Gynecology.) 


CHANGES  FELT  IN  THE  CERVIX  231 

Tumor  of  Vaginal  Wall.  This  is  usually  a  cyst.  A  rounded  mass  containing, 
fluid  is  felt  and,  tracing  it  up,  it  is  found  to  be  attached  to  the  vaginal  wall  (Fig. 
326).  It  can  not  be  reduced  into  the  peritoneal  cavity  lilve  a  hernia,  neither  is  there 
any  evidence  of  any  obstructive  bowel  disturbance.  Solid  tumoi-s  of  the  vaginal 
wall  sometimes  occur. 

Vaginal  Hernia  (Fig.  327).  This  is  felt  as  a  soft  elastic  mass,  causing  projection 
of  the  vaginal  wall.  It  can  be  reduced  into  the  peritoneal  cavity  but  returns  when 
the  patient  coughs  or  bears  down.  It  disappears  when  the  patient  is  in  the  knee- 
chest  posture,  unless  strangulated  or  incarcerated.  There  may  or  may  not  be  sym- 
toms  of  intestinal  obstruction,  partial  or  complete. 

Abscess  Pushing  Vaginal  Wall  Inward.  Such  an  abscess  may  arise  in  the  con- 
nective tissue  beside  the  cervix  or  in  the  posterior  cul-de-sac  or  in  front  of  the  cer- 
vix or  as  an  ischio-rectal  abscess.     It  may  arise  also  in  the  recto-vaginal  septum. 

Rectum  Distended  with  Fecal  Masses.  If  the  fecal  masses  are  in  the  lower  part 
of  the  rectum  their  character  is  apparent,  but  if  in  the  upper  part  of  the  rectum, 
back  of  the  uterus,  they  may  be  confused  with  other  masses.  The  characteristics 
of  such  a  fecal  mass  are  that  it  is  situated  in  the  course  of  the  rectum,  that  it  is  not 
particularly  tender,  that  it  has  a  putty-like  consistency  and  may  be  indented  by 
the  examining  finger  and  the  dent  remains,  that  it  may  be  moved  along  to  a  dif- 
ferent part  of  the  rectum  and  that  an  enema  removes  it. 

Tumor  of  Rectum.  There  is  a  mass  felt  through  the  posterior  vaginal  wall. 
There  are  the  evidences  of  rectal  irritation  and  also  the  facts  that  may  be  made  out 
on  rectal  examination. 

Tumor  of  Bladder.  A  mass  is  felt  through  the  anterior  vaginal  wall.  There  are 
the  evidences  of  bladder  irritation  (frequent,  painful  urination)  and  also  the  urinary 
findings. 

Mass  in  CuI=de=Sac  of  Douglas.  This  is  felt  back  of  the  cervix  and  may  be  a  re- 
troflexed  uterus  (Fig.  393),  a  tumor  (Fig.  392),  a  prolapsed  ovary  or  tube  (Fig.  391), 
an  inflammatory  exudate  (Fig.  401),  an  abscess  or  a  hematocele. 

CHANGES  IN  CERVIX  UTERI    FELT  ON 
VAGINAL  EXAMINATION. 

Displacement  of  Cervix.  Forward  Displacement  (pointing  forward)  may  be  due 
to  backward  displacement  of  the  uterus  (Figs.  328,  329),  to  anteflexion  of  the  cer- 
vix (Fig.  330)  or  to  an  inflammatory  mass  or  a  tumor  back  or  the  cervix  pushing  it 
forward.  Backward  Displacement  may  be  due  to  a  distended  bladder  (Fig.  344), 
or  a  tumor  of  the  bladder,  to  an  inflammatory  mass  or  a  tumor  in  the  front  part  of 
the  cervix  pushing  it  backward  or  to  old  adhesions  back  of  the  cervix  pulling  ii 
backward.  Lateral  Displacement  of  the  cervix  may  be  due  to  an  inflammatoiy 
mass,  a  blood  mass  or  a  tumor  at  the  side  of  the  cervix  pushing  it  toward  the  oppo- 
site side,  or  to  old  adhesions  or  to  scar  tissue  in  the  vaginal  wall  on  one  side  pulling 
the  cervix  to  the  same  side. 

Enlargement  and  Distortion  of  the  Cervix  may  be  caused  by  inflammation  with 
e version  of  mucosa  (Fig.  331), or  by  laceration  with  eversion  of  mucosa  (Figs. 332  to 
337), or  by  chronic  inflammatory  infiltration  and  obstruction  of  gland  ducts  from 


232 


GYNECOLOGIC  DIAGNOSIS 


I 


i 


Fig.  328.  Fig.  329. 

The  Relation  of  the  Cervix  to  the  Examixisg  Fixger. 
Fig.  328.     Retroversion  of  the  Uterus,  showing  the  Relation  of  the  Cer\'ix  to  the  examining  finger.     Com- 
pare this  with  Fig.  329,  which  shows  the  relation   of   the  cervix  to  the  examining  finger  when  the  uterus  is  in 
uormal  position.      (Keating  and  Coe — Clinical  Gynecology.) 


Fig.  330.      Anteflexion    of    the  Cen'ix  Uteri.      In    this   condition  the  axis  of  the  cervix  points    toward  the 
examiner,  as  in  retroversion,  though  the  corpus  uteri  is  well  forward. 


SWELLING  AND  EVEKSlUN    FROM   INi'LA.NLMATlUN 


233 


Fig.  331.  Eversion  of  the  Cervical  Mucosa  due  to  inflammation  within  the  cervix. 
(Cullen — Cancer  of  the  uterus.) 

There  has  been  no  laceration  of  the  cervix  in  this  case,  the  patient  being  a  Nullipara.  This 
eversion  of  the  cervical  mucosa  by  inflammation  only,  without  previous  laceration,  is  a  rare  con- 
dition. It  is  likely  to  lead  to  a  mistaken  diagnosis  of  laceration  of  the  cervix.  It  is  also  of 
medico-legal  importance,  as  the  appearance  of  laceration  may  lead  to  the  erroneous  conclusion 
that  the  patient  has  at  sometime  given  birth  to  a  child. 


23* 


GYNECOLOGIC  DIAGNOSIS 


scar-tissue,  causing  cystic  degeneration  (Fig.  337),  or  by  a  fibroid  tumor  of  the  cer- 
vix or  by  a  malignant  tumor  of  the  cervix.  Idiopathic  elongation  of  tlie  cervix, 
also,  may  cause  it,  but  that  is  a  very  rare  condition. 

Softening  of   the  Cervix  may  be   due  to  normal  pregnancy  or  to  extra-uterine 
pregnancy  or  to  a  recent  pregnancy  (terminated  by  labor  or  miscarriage).     In  Fig. 


Fig.  332.  Fig.  333. 

Figs.  332  and  333,  Side  and  Front  Views  of  a  Simple  Bilateral  Laceration,  requiring  no  treatment. 


Fig.  334.     Front  view  of  a  Unilateral  Laceration 
requiring  no  treatment. 


Fig.  335.  Side  View  of  a  Unilateral  Lacera- 
tion. Such  a  laceration  may  cause  abor- 
tion in  the  early  months  of  pregnancy. 


Fig.  336.    Side  View  of  a  Bilateral  Fig.  337.     Front  View  of   a  Bi- 

Laceration,  requiring  treatment.  The  lateral  Laceration,  showing  eroded 

lip.s  are  everted,  and   the  Nabothian  area  and  Nabothian  follicles, 

follicles     stand    out    as    small    hard 
lumps. 

Figs.  332  to  337.     Lacerations  of  the  Ceuvix  Uteri.  (Baldy— .//"erjcinj  Teiit-hook  of  (ii/necologi/.) 


338,  the  softened  portion  is  represented  by  the  dotted  area.  This  feels  soft,  like  the 
vaginal  wall  or  like  velvet,  as  explained  in  chapter  i.  It  has  been  aptly  said  that  "  the 
cervix  normally  has  about  the  consistency  of  the  tip  of  the  nose.  When  it  is  as  soft 
as  the  lip,  look  out  for  pregnancy. "  This  softening  begins  at  the  lower  part  of  the 
cervix  in  the  first  few  weeks  of  pregnancy  and  gradually  progresses  upward  until,  in 


CHANGES  IN  THP:  CONSISTENCY  OF  THE  CERVIX 


235 


the  last  month,  the  whole  cervix  is  so  softened  that  it  is  sometimes  hardly  felt  in  the 
examination.  That  this  is  a  softening,  and  not  a  shortening  as  was  formerly  sup- 
posed, is  shown  in  Fig.  339,  where  it  is  seen  that  the  cervix  at  term  is  still  of  normal 
length.  Occasionally  marked  chronic  congestion,  from  the  presence  of  a  tuinoy  or 
inflammatory  mass,  will  be  accompanied  by  sonic  softening  or  the  cervix. 


Fig.  338.  Palpating  the  Cervix  to  Determine  Softening. 
The  light  stippled  area  represents  the  softened  portion. 
The  uterus  is  represented  as  enlarged  from  early  pregnancy. 


Fig.  339.  Section  of  the  Cer- 
vix, in  pregnancy  at  term,  show- 
ing that  the  cervix  is  still  of  Full 
Length.  The  sensation  of  short- 
ening imparted  to  the  examining 
finger  is  due  to  the  softening, 
causing  the  lower  part  to  be  not 
easily  appreciated  by  the  finger- 
(Dickinson,  after  Waldoyer — 
American  Textbook  of  Obxtet- 
rics.) 


Fig.  340.  Beginning  Carcinoma  within  the  Cervix, 
causing  a  Hard  Nodule,  which  can  be  felt  on  digital  ex- 
amination.    (Kelly— Operative  Gynecology.) 


236 


GYNECOLOGIC  DIAGNOSIS 


Hard  Nodule  in  the  Cervix  may  be  due  to  scar  tissue  from  laceration,  to  a  fibroma, 
to  beginning  malignant  disease  (Fig.  340)  or  to  a  glandular  cyst  (Fig.  341).  In  scar 
tissue,  the  induration  corresponds  with  the  scar  and  follows  the  course  of  the  scar, 
and  it  does  not  increase  in  size  under  observation.  In  cystic  disease  (Figs.  560,  341), 
if  the  nodule  be  punctured  and  pressed  upon,  the  characteristic  clear  glairy  substance 
will  be  extruded  and  the  induration  will  largely  disappear.  In  fibromyoma. 
fibroids  elsewhere  in  the  uterus  may  be  found,  making  it  probable  that  the  cervi- 


Fig.  341.  Cysts  of  the  Cervix.  These  feel  like  Hard  No- 
dules and  hence  may  lead  to  a  mistaken  diagnosis  of  malig- 
nant disease  in  the  cer^'ix,  as  happened  in  the  case  from 
which  this  specimen  was  taken.  At  operation  the  car- 
cinoma (which  was  diagnosed  from  curettings)  was  found 
to  be  confined  to  the  corpus  uteri,  as  shown  in  the  speci- 
men, instead  of  extending  to  the  cerv^ix  as  was  previously 
supposed.      (Kelly — Operative  Gynecology.) 


cal  nodule  is  similar  in  nature.  A  nodule  in  the  cervix  that  does  not  correspond 
with  any  of  the  conditions  just  mentioned,  may  be  beginning  malignant  disease. 
A  piece  of  it  should  be  excised  and  submitted  to  microscopic  examination,  to 
establish  certainly  the  diagnosis  at  a  time  when  a  diagnosis  will  do  some  good. 

Tenderness  of  the  Cervix  usually  means  inflammation  around  the  uterus.  The 
tissue  of  the  cervix  is  ordinarily  not  painful  to  pressure  even  when  diseased.  The 
tenderness  so  often  complained  of  when  pressure  is  made  on  the  cervix,  is  usually 


POLYPI  IN  THE  CERVIX 


237 


due  to  a  slight  involvment  around  the  uterus  and  consequent  pulUng  on  in- 
flamed peri-uterine  tissues  due  to  the  moving  of  the  uterus. 

Fixation  of  the  Cervix  may  be  due  to  inflammatory  exudate,  to  a  tumor  about 
the  uterus  or  to  scar  tissue  in  the  upper  part  of  the  vagina. 

Abnormal  Mobility  of  the  Cervix  is  due  to  stretching  of  the  supporting  tissues 
around  it  and  of  the  pelvic  floor  below  it. 

MASS  FELT  IN  CERVICAL  CANAL. 

On  palpating  the  cervix  some  one  of  the  following  small  masses  may  in  some 
cases  be  felt  just  within  the  external  os  or  projecting  slightly  from  it. 

Blood  Clot.  This  is  soft  and  easily  broken,  if  it  projects  far  enough  to  permit  of 
its  being  caught  between  the  fingers.     When  it  is  up  in  the  canal  so  that  only  the 


Fig.  342.     Mucous  Polj-pi  of  the  Cervix.     (Jliist— Diseases  of  Women.) 


238  GYNECOLOGIC  DIAGNOSIS 

lower  edge  or  end  can  be  felt,  it  may  feel  very  much  like  a  piece  of  tissue.  Intro- 
duce the  uterine  dressing  forceps  beside  the  finger  and  catch  the  small  mass  and 
bring  it  outside  for  inspection. 

Placental  Remnants.  In  incomplete  miscarriage  a  small  piece  of  tissue  may 
often  be  felt  in  the  cervical  canal,  showing  that  there  are  retained  remnants  that 
must  be  removed.  It  is  in  this  same  class  of  cases  that  a  firm  blood  clot  in  the  cer- 
vix  may  lead  to  an  erroneous  diagnosis,  hence  the  importance  of  removing  the 
small  mass  with  a  forceps  so  that  it  may  be  examined  to  determine  certainly 
whether  it  is  a  piece  of  tissue  or  only  a  blood  clot.  To  determine  if  it  has  the  bushy 
projections  of  placental  tissue,  spread  it  out  in  water.  If  it  is  of  doubtful  char- 
acter, submit  it  to  microscopic  examination.  It  may  be  a  broken  off  papillary 
mass  from  a  malignant  growth  in  the  uterus. 

Mucous  Polypus.  Mucous  polypi  are  frequently  found  projecting  from  the  cer- 
vix or  up  in  the  canal  (Fig.  342) .  They  may  be  so  soft  as  to  be  hardly  noticed  in  the 
digital  examination  but,  when  projecting  from  the  canal,  are  very  apparent  in  the 
speculum  examination. 

Fibrinous  Polypus.  This  is  a  polypus  which  has  gradually  enlarged  from  accre- 
tions of  fibrin  about  a  placental  remnant  or  other  small  mass  in  the  uterine  cavity. 
Its  character  is  determined  bj"  microscopic  examination. 

Fibroid  Polypus  (Fig.  307).  This  is  a  small  pediculated  submucous  fibroid,  the 
pedicle  of  which  has  become  stretched  sufficiently  to  permit  the  mass  to  appear  at 
the  external  os  or  to  project  from  the  same.  It  may  be  attached  in  the  body  of  the 
uterus  or  in  the  cervix,  usually  the  former. 

Malignant  Polypus.  A  malignant  growth  in  the  cervix  or  in  the  body  of  the 
uterus  may  send  out  a  papillarj^  projection  that  appears  at  the  external  os  as  a  poly- 
pus. Again  malignant  change  may  be  present  in,  or  may  develop  in,  apparently 
simple  poh^i.  For  this  reason  all  polypi  of  whatever  kind  removed  from  the  cer- 
vis.  should  be  preserved  that  their  exact  character  may  be  determined  by  micro- 
scopic examination. 


POINTS  IN  THE  VAGINO=ABDOMINAL  EXAMINATION. 

CHANGES  IX  CORPUS  UTERI. 

Backward  Displacement  of  the  Uterus  (Fig.  343) ,  The  body  of  the  uterus  is  not 
made  out  in  front  (Fig.  69).  In  the  back  part  of  the  pelvis  there  is  felt  a  body,  ap- 
parently continuous  with  the  cervix,  and  of  the  size,  shape  and  consistency  of  the 
corpus  uteri  (Figs.  70,  71).  It  may  bo  movable  or  fixed,  tender  or  not  tender.  No 
other  mass  is  felt  in  the  pelvis.  Such  a  mass  is  in  all  probability  the  bod}'  of  the 
uterus  in  backward  displacement.  If  some  of  the  necessary  points  can  not  be  made 
out  distinctly  and  there  are  circumstances  which  make  it  important  to  know  at 
once  the  exact  location  of  the  corpus  uteri,  this  may  be  determined  certainly  by 
introducing  the  sound  into  the  uterus.  But  do  not  use  the  sound  except  when 
there  is  some  special  reason  for  doing  so,  and  remember  the  contra-indications  to 
sounding  given  in  chapter  i. 


POINTS  IN  THE   BIMANUAT.  i:\AMlNATION 


239 


This  retro-displacement  of  the  body  of  the  uterus  may  be  due  to  a  full  bladder 
(Fig.  344)  or  to  an  infianmiatory  mass  in  the  front  part  of  the  pelvis  or  to  a  tumor. 
On  the  other  hand,  the  displacement  itself,  with  or  without  an  accompanying  in- 
flammatory trouble,  may  be  the  principal  lesion. 


Fig.  343.    Retrodisplacement  of  the  Uterus,   showing  the  first, 
second  and  third  Degrees.     (Skene — Diseases  of  Women.) 

Forward  Displacement  of  the  Uterus.  Forward  displacement  of  the  body  of  the 
uterus  may  be  due  to  the  body  of  the  uterus  being  heavy  and  softened,  as  in  early 
pregnancy  (Fig.  348)  and  also  in  certain  inflammatory  conditions,  or  to  an  inflam- 
matory mass  or  a  tumor  pushing  the  fundus  forward  and  downward. 

Lateral  Displacement  of  the  Uterus  may 
be  caused  by  an  inflammatory  mass  (Fig. 
345)  or  by  blood  a  mass  (Fig.  387)  or  by  a 
tumor  (Fig.  346),  pushing  the  uterus  toward 
the  opposite  side.     It    may  be  due  also  to 


Fig.  344.  Uterus  displaced  backward  by  i 
?ull  Bladder.  (Montgomery — Practical  Gynec- 
ology.) 


VAGINA 
RECTUM 

Fig.  345.    Uterus  displaced  laterally  by  an  In- 
flammatory Mass.     (Edgar— Prrtcitce  of  Obstetrics.) 


240 


GYNECOLOGIC  DIAGNOSIS 


old  adhesions  drawing  the  uterus  to  the  side  (Fig.  347),  or  it  may  be  due  simply  to 
a  heavy  uterus  leaning  to  the  side. 

Slight  Enlargement  of  the  Uterus  may  be  caused  by  early  pregnancy.     There  is 
usually  decided  anteflexion  of  the  softened  uterus  in  this  early  stage  (Fig.  348), 


Fig.  346.  Uterus  pushed  to  the  left  side  by  a  Tumor  or  Inflam- 
matory Mass  in  the  opposite  side.  (Findley  —  Diagnosis  of 
Diseases  of  Women.) 


Fig.  347.     Uterus  Drawn  to  the  left  side  by  Adhesions  or  Infiltra- 
tion in  the  same  side.     (F'mdXey— Diagnosis  of  Diseases  of  Wometi.) 


Occasionally  there  is  backward  displacement  of  the  pregnant  uterus  (Figs.  349, 
350).  From  about  the  sixth  to  the  twelfth  week  there  is  a  peculiar  softening  and 
compressibility  of  the  lower  portion  of  the  body  of  the  uterus  which  contrasts 
markedly  with  the  less  compressible  portion  above.     This  is  known  as  Hegar's 


SLIGHT  ENLARGMKNT  OF  Till-:  UTERUS 


\'A\ 


Pdr'es-  recti 


Vesica  urin.  • 


V.  dorsalis  clitor.  " 


Clitoris 


Flacmfa 
Grif.  inf.  uteri 

Orif.  ext.  nteri 
Excav.  vesica 


Fornix 
vagin.  post. 


^f.  sphincter 
ani  ext. 


Tunica  muscul.  recti 


M.  sphincter  ani  ext. 
Urethra 
Tunica  muscul.  urethr.  Vagina 

P'ig.  348.     Frozen  Section  of  a  body  showing  the  Uterus  Enlarged  from  early  Pregnancy.     Notice  the  sluvrp 
anteflexion  of  the  softened  uterus.      (Waldeyer — Das  Becken.) 


242 


GYNECOLOGIC  DIAGNOSIS 


Fig.   349.      Early    Pregnancy    with  Retrodisplaeement   of  uterus. 
(Edgar— Practice  of  Obstetrics.) 


Fig.  3.50.     Early  Pregnancy  with  a  more  marked   Reir-...)is|.lapcment 
of  the  uterus.    (Edgar— Pmcrice  of  Obstetrics.) 


HEGAR'S  SIGN  IN  EARLY  PREGNANCY 


24? 


Fig.  351.     A  Sectioned  Uterus  in  early  Pregnancy,  showing  the  two   halves  and  the  interior  arrangement  whicli  gives 
ilepar's  Sign.      (Edfrar,  after  Pinard — Practice  of  Ohstetrica.) 


Fig.  .3.52.  Showing  the  Sen.sat ions  im- 
parted to  the  examining  fingeis  by  dif- 
ferent portions  of  the  uterus  in  Early 
Pregnancy,  particularly  the  marked  Com- 
pressibility of  the  portion  just  above  the 
internal  OS  (Hegar's  Sign).  (Dickinson — 
American  Text -book  of  Obstetrics.) 


Fig.  353.  Palpating  for  Hegar's  Sign,  with 
the  uterus  forward  in  the  usual  position. 
(Edgar— Practice  of  Obstetrics.) 


:=£?•■' 


A' 


Fig.  354.  Palpating  for  Hegar's  Sign,  with  the  fundus 
uteri  pushed  backward, the  abdominal  fingers  being  in  front 
and  the  vaginal  fingers  back  of  the  rer\-ix.  (Williams— 
Obstetrics.) 


244 


GYNECOLOGIC  DIAGNOSIS 


sign,  and  when  well  marked  is  a  strong  indication  of  early  pregnancy.  Fig.  351 
shows  the  section  of  a  uterus  in  early  pregnancy.  Fig.  352  explains  the  sensation 
imparted  to  the  examining  finger.  The  examination  may  be  made  in  the  usual 
way,  with  the  abdominal  fingers  back  of  the  uterus  (Fig.  353),  or  the  abdominal 
fingers  may  be  pressed  in  front  of  the  fundus 
uteri,  which  is  displaced! somewhat  backward, 
while  the  vaginal  fingers  are  placed  behind 
the  uterus  (Fig.  354). 


Fig.  355.  Hard  Nodules  in  tlie  Corpus  Uteri,  due 
to  small  Fibromyomata.  (Montgomery— Practical 
Gynecology.) 


Fig.  356.  Larger  Fibromyomata,  in  var- 
ious situations  in  the  uterine  wall.  (Schaef- 
fer — Hand-Atlas  of  Gynecology.) 


SHght  enlargement  of  the  uterus  may  be  due  also  to  tubal  pregnancy  or  to  chronic 
inflammation  or  to  one  or  more  fibroid  tumors  (Figs.  355,  356,  357,  358)  or  to  car- 
cinoma of  the  corpus  uteri  (Fig.  359)  or  to  sarcoma  (Fig.  360)  or  to  lipoma  (Fig. 
361)  or  to  pyometra  (Fig.  382)  or  to  tuberculosis  of  the  uterus  (Fig.  362). 

Marked  Enlargement  of  the  Uterus  may 

be  due  to  normal  pregnancy  (Figs.  363, 
364,  365.)  Figs.  366  and  367  show  the 
height  of  the  fundus  at  the  various  weeks 
of  a  normal  pregnancy.  Bear  in  mind  that 
the  pregnant  uterus  is  not  always  regular 
in  shape,  but  is  occasionally  quite  irreg- 
ular (Figs.  368,  369,  370).  Enlargement 
may  be  due  also  to  a  pregnancy  somewhat 
abnormal,  for  example,  presenting  back- 
ward displacement  or  hy  dramnios  or  hyda- 
tidiform  mole  or  hematom-mole.  Again, 
marked  enlargement  of   the   uterus  may 

Fig.  357.      Other  varieties   of    Fibromyomata,  be   CaUSed   by   interstitial  prCgUaUCy  (Fig. 

giving  rise  to  a  diffuse  and  more  uniform  enlarge-  371)  Or  by  pregUaUCy  in    a  SCptate    UtcrUS 

ment   of    the  uterus.      (Montgomery— frac^isoZ  /"P'tr    ^79^ 

Gynecology.)  \'^'^&-  ■^1  ^)  • 


SLIGHT  ENLARGEMENT  OF  UTERUS 


245 


Fig.  358.    A  Single  Fibroid,  in  the  posterior  wall  of  the  uterus.     (Byford- 
Manual  of  Gynecology.) 


Fig.  359.    Slight  Enlargement  of  the  Corpus  Uteri  caiised  by  Carcinoma. 
(Cullen— Cancer  o/<fte  Uterus.) 


246 


GYNECOLOGIC  DIAGNOSIS 


Fig.  360.       Slignt  Enlartrement    of    the     Uterus  caused    by  Sacoma. 
(Cullen — Caiicero/tfie  Uterus.) 


ENLARGEMENT  OF  UTERUS    FROM    l.U'O.MA 


247 


V7A  ll 


i[  IS   M.       J-  <>  I 


Fig  361  A  Lipoma  of  the  Posterior  Uterine  Wall.  Notice  the  cavity  of  the  uterus  running  along  the  anterior 
wall,  and  the  marked  thickening  of  the  endometrium  near  the  fundus.  This  is  an  exceedingly  rare  form  of  uterine 
tumor.     (Knox— Johns  Hopldns  Hoapital  Bulletin.) 


248 


GYNECOLOGIC  DIAGNOSIS 


Fig.  362.  Tuberculosis  of  the  Uten^s.  This  specimen  was  removed 
by  supravaginal  hysterectomy,  the  lower  portion  of  the  cervix 
being  left.     (J.  Bland-Sutton— ^ssaj/s  on  Hysterectomy.) 


n 


'  Fig.    363.       Pregnancy,    about     four    months. 
fEdgar— PrffctJce  of  Obstetrics.) 


ENLARGEMENT  FROM  ADVANCED  PREGNANCY 


249 


Fig  364.     Pregnancy,  about  five  months.     (Edgar- 
Practice  of  Obstetrics.') 


Fig.  365.    Pregnancy    at    Full    Term.      (Edgar- 
Practice  of  Obstetrics.) 


Fig.  366.  The  Pregnant  Uterus  contrasted  with  the  non-preg- 
nant uterus,  showing  the  enormous  increase  in  size.  The  height 
of  the  fundus  at  various  weeks  of  pregnancy  is  indicated  by  the 
numbers.    (Dickinson — American  Textbook  of  Obstetrics.) 


250 


GYNECOLOGIC  DIAGNOSIS 


Fig.  367.    The  Height  of  the  Fundus  Uteri  at  various  weeks  of 
Pregnancy.     (SVi\]ia.ms— Obstetrics.) 


Fig.  369. 


Fig.  370. 


Fig.  368. 

Figs.  368  and  369  and  370.    Irregular  Shapes    that    Pregnant  Uteri    may  present,  and  which  may  lead  to  mis- 
takes in  diagnosis.     (Edgar— Practice  of  Obstetrics.) 


ENLARGEMENT  FROM  ABNORMAL  PREGNANCY 


251 


AmRion 


Ulerine  cavity.- 


.ervix.  - 


Partially  separated 
placenta. 


Fig.  37L    Interstitial  Pregnancy.     (Williams,  after  Bximm— Obstetrics.) 


Fig.  372.    Pregnancy  in  the  RightHalf  of  a  Septate  ffenxs.    (Kelly 
-Operative  Gynecology.) 


252 


GYNECOLOGIC  DIAGNOSIS 


Aside  from  pregnancy,  the  usual  causes  of  marked  enlargement  of  the  corpus 
uieri  are  fibromyomata  (Figs.  373;  374,  375,  376,  377)  and  malignant  disease  (Fig 
378). 


Fig.  373.    Uterus  Enlarged  by  a  large  soft  single  Fibroid.   (Bishop—  Uterine  Fibromyoviata.) 


In  some  cases  there  is  an  association  of  fibroid  and  pregnancy  (Figs.  379,  380)  or 
o:  malignant  disease  and  pregnancy  (Fig.  421). 

In  rare  instances  the  uterus  has  become  enlarged  from  menstrual  blood  retained 


ENLARGEMENT  OF  UTERtJS  FROM  FIBROIDS 


25.' 


Fig  374.  Uterus  Svmmetically  Enlarged  from  Fibroids.  This  might 
be  mistaken  for  a  pregnant  uterus,  on  account  of  the  close  resemblance  in 
shape.      (Kelly— Operative  Oynecologij.) 


Fig.  375.    Subperitoneal   Fibroids,  showing  the   irregularity  and  distor- 
tion  often  present.    {KeWy— Operative  Gynecology.) 


254 


GYNECOLOGIC  DIAGNOSIS 


Fig.  376.    Single  Large  Fibroid   in  anterior  uterine  wall,  choking  Fig.  377.    Large  Fibroids,  filling  the  pelvi.s  and 

tliepeivi.s.     (Kelly— Operative  Gynecology.)  lower  abdomen.   {\.Ma.rtin— Atlas  of  Gynecology.) 


Fig.  378.  LUerus  Enlarged  from  Carcinoma.  The  in- 
terior of  the  uteru.s  is  occupied  by  the  growth  and  it  has 
extended  through,  forming  some  nodules  on  the  outer 
surface.     (Kelly — Operative  Oi/nerotagy.) 


Fig.  .'^79.  I'iljiiiid  Tumor  and  Pregnancy,  the 
tumor  forming  tlie  most  of  the  mass.  (Dudley — 
Practice  of  Gynecology.) 


1 


ITERUS  EM.ARCKD   llioM  OTHER  CAUSES 


255 


because  of  atresia  of  the  cervix  (hematometra,  Fig.  381)  or  from  a  collection  of  pus 
(pyometra)  or  of  pus  and  gas  (pyophysometra,  Fig.  382). 

Softening  of  the  Corpus  Uteri  is  caused  by  the  various  forms  of  intra-uterine  preg- 
nancy. In  most  cases  of  early  pregnancy  the  characteristic  compressibility  of  a 
portion  of  the  uterus  (Hegar's  sign)  may  be  made  out,  and  when  well  marked  is  of 


Fig.  380.  Fibroid  Tumor  and  Pregnancy,  the 
pregnancy  forming  the  larger  part  of  the  mass. 
(Norris,  after  Simpson — American  "^^^t-hool:  of 
Obstetrics.) 


Fig,  .381.  Uterus  distended  with  Menstrual  Blood 
(Hematometra),  due  to  atresia  of  the  cervix.  (Mont- 
gomery—  Prartiral  Gynecology.) 


(ten  assistance  in  differential  diagnosis. 
Softening  of  the  corpus  uteri  may  be 
caused  also  by  extra-uterine  pregnancy 
and  likewise  by  a  recent  pregnancy  (i.  e., 
for  a  few  weeks  following  labor  or 
miscarriage).  It  is  caused  also  by  edema 
of  the  uterine  wall,  from  adjacent  in- 
flammation or  from  a  tumor  interfering 
wAth.  the  circulation  or  from  marked  dis- 
placement. 

Hard  Nodules  felt  in  the  Corpus  Uteri 
may  be  due  to  parts  of  the  child  in  preg- 
nancy or  to  fibromyomata  or  to  a  malig- 
nant tumor.  In  rare  cases  an  athero- 
matous or  sclerotic  process  may  cause 
hardening  of  areas  appreciable  to  the 
finger.  Also,  a  mass  of  exudate  or  some 
adherent  structure  may  cause  a  hard  mass 
that  appears,  on  bimanual  examination, 
to  be  a  part  of  the  uterus. 


Fig.  382.  Uterus,  enlarged  by^  collection  of  Pus 
and  Gas  (Pyophysometra)  above  an  occluded  canper- 
ous  cervix.      (Kelly — Operative  Gynecology.) 


256  GYNECOLOGIC  DIAGNOSIS 

Marked  Tenderness  of  the  Uterus  may  be  caused  by  inflammation  of  the  uterus, 

by  inflammation  around  the  uterus,  by  hemorrhage  around  the  uterus,  by  pelvic 
neuralgia  or  by  functional  hyperesthesia  (hysteria,  neurasthenia). 

Fixation  of  the  Uterus  may  be  due  to  an  inflammatory  mass,  to  a  hemorrhagic 
mass,  to  old  adhesions,  to  a  new  growth  or  to  scar  tissue  from  vaginal  laceration. 

Abnormal  Mobility  of  the  Uterus  is  due  to  overstretching  of  the  supports  around 
it  and  of  the  pelvic  floor  below  it. 


MASS  OR  INDURATION 

In  Pelvis  or  Lower  Abdomen,  Felt  ox  Bimaxual  Examination. 
MASS  LOW  in  Pelvis,  and  to  RIGHT  of  Cervix. 

A.     Mass  or  Induration  FIRM  (No  Fluid  Felt). 

1.  Body  of  the  Uterus  Displaced  to  the  Right.  The  mass  is  directly  continuous 
with  the  cervix  and  is  about  the  size  and  shape  of  the  body  of  the  uterus.  The 
uterus  can  not  be  felt  elsewhere.  If  not  adherent  or  very  tender,  it  may  be  pushed 
back  to  the  normal  position  of  the  corpus  uteri.  The  uterus  may  he  somewhat  to 
one  side,  though  freely  movable,  or  it  may  be  dra-oii  to  one  side  by  adhesions,  or 
it  may  be  pushed  over  by  a  tumor  or  an  inflammatory  mass  or  a  blood  mass. 

The  displaced  uterus  may  be  of  a  normal  size  or  it  may  be  enlarged.  If  enlarged, 
it  may  be  of  regular  shape  or  distorted.  It  may  be  of  normal  consistency  or  soft- 
ened or  presenting  hard  nodules.  If  there  is  inflammation  in  the  uterus  or  around 
it,  it  may  present  decided  tenderness.  Whether  it  is  movable  or  fixed  depends 
on  the  cause  of  the  displacement.  If  there  is  attachment  by  adhesions  to  the  pelvic 
wall  or  to  an  inflammatory  mass  or  to  a  tumor,  determine  whether  it  is  at  the  lower 
or  upper  part  of  the  uterus. 

2.  Salpingitis  -Cvith  Exudate,  extending  to  the  side  of  the  cul-de-sac.  The  in- 
flamed tube  itself  is  situated  higher,  but  some  fibrinous  peritoneal  exudate  has 
extended  doT\m  so  that  it  is  felt  to  the  right  side  of  the  cervix  posteriorly. 

3.  Salpingitis  with  Prolapse  of  Thickened  Tube.  The  enlarged  and  indurated 
tube  may  be  movable,  or  it  may  he  bound  in  its  abnormal  situation  by  adhesions. 

4.  Salpingitis  with  Secondary  Infiltration  of  the  connective  tissue  about  the  cer- 
viz.  This  presents  practically  the  same  signs  low  in  the  pelvis  as  a  primary  cellu- 
litis, but  in  addition  there  is  felt  higher,  the  mass  formed  by  thickened  tube  and 
peritoneal  exudate. 

5.  Oophoritis  with  Prolapse  of  Ovary.  The  ovary  is  usually  enlarged  and  cystic, 
but  none  of  the  cysts  are  yet  large  enough  to  give  distinct  fluctuation.  Ordinarily, 
the  ovary  feels  much  softer  on  palpation  than  either  an  infiltrated  tube  or  a  mass  of 
exudate.  This  softness  may  be  so  marked  as  to  lead  to  the  erroneous  idea  that 
fluctuation  (a  well  marked  cyst)  is  present,  while  in  fact  the  ovarian  tissue  may  be 
practically  normal.  The  chronically  inflamed  ovary  is  occasionally  as  firm  as 
other  tissue  which  is  the  seat  of  inflammatory  infiltration.  This  is  the  case  partic- 
ularly in  the  cirrhotic  ovary,  which  is  also  usually  smaller  than  the  normal  ovary. 


SOLID  MASS  TO  RIGHT  OF  CERVIX   UTERI 


257 


The  fact  that  the  mass,  felt  to  the  right  of  the  cervix  posteriorly,  is  the  ovary,  is 
determined  by  noticing  its  position,  size,  shape,  consistency,  tenderness,  mobility 
and  point  of  attachment.  The  ovary  is  usually  decidedly  tender,  even  when  nor- 
mal, and  pressure  upon  it  produces  a  peculiar  sickening  pain. 

One  of  the  characteristics  of  the  prolapsed  ovary,  when  not  adherent,  is  that  it  is 
freely  movable.  It  slips  away  from  the  examining  finger  and  may  he  pushed  up 
out  of  the  lower  part  of  the  pelvis.  Following  the  mass  up  and  making  deep  bi- 
manual palpation,  its  point  of  attachment  is  found  to  be  in  the  tubo-ovarian  region. 
If  there  has  been  any  peritoneal  exudate,  the  ovary  is  likely  to  be  fixed  in  its  abnor- 
mal position  by  adhesions. 

6.  Small  Abscess  from  any  of  the  above  conditions,  near  the  posterior  lateral  part 
of  the  cervix  and  with  such  a  thickened  wall  that  no  fluctuation  is  obtained.  There 
is  a  point  of  marked  tenderness,  with  fixation  of  the  tissues  in  the  vicinity.  If  of 
recent  origin  there  will  be  some  fever,  but  in  an  old  abscess  the  temperature  may  be 
practically  normal.  The  history  of  the  trouble  and  the  findings  elsewhere  in  the 
pelvis,  will  indicate  the  character  of  the  primary  lesion. 


Fig  383.  The  Three  Spaces  or  Areas  in 
the  Pelvis.  A.  Peritoneal  Cavity.  B.  Sub- 
peritoneal connective  tissue  area  or  Parame- 
tria! Space.  C.  Ischio-rectal  Space.  The 
white  line  between  B  and  C  represents  the 
levator  ani  muscle.  (Dudley — Practice  of 
Gynecology.) 


Fig.  384.  On  the  right  is  a  large  inflam- 
matory mass  in  the  Parametrial  Space.  This 
is  what  is  meant  ordinarily  by  the  term  Pelvic 
Cellulitis. 

On  the  left  is  a  small  inflammatory  mass  in 
the  Ischio-rectal  Space.  From  inflammatory 
trouble  in  this  region  comes  the  well-known 
Ischio-rectal  Abscess.  (Dudley — Practice  of 
Gynecology.) 


7.  Adhesions  at  the  side  of  the  cervix  from  any  of  the  above  affections.  In  the 
absence  of  pus  or  active  inflammation,  there  is  usually  not  much  tenderness.  The 
principal    signs  are  induration,  without  a  definitely-outlined  mass,  and  fixation. 

8.  Cellulitis.  This  may  be  acute  or  subacute.  The  induration  is  situated  very 
low  and  blends  with  the  cervix.  It  may  be  a  small  mass  or  may  fill  all  that  side  of 
the  pelvis,  extending  out  to  the  pelvic  wall.  As  a  rule  its  shape  corresponds  ap- 
proximately with  the  connective  areas  (Fig.  383).  If  the  inflammation  is  in  the 
parametrium  (above  the  levator  ani),  it  is  immediately  about  the  cervix  (Fig.  384). 
If  it  is  below  the  levator  ani,  in  the  ischiorectal  space,  the  induration  will  be  lower, 
along  the  vaginal  wall  and  rectum,  and  there  will  be  induration  near  the  anus.     In 


258  GYNECOLOGIC  DIAGNOSIS 

pelvic  cellulitis,  except  in  the  acute  cases,  the  induration  feels  exceptionally  hard, 
possibly  because  there  is  but  little  intervening  soft  tissue  between  the  examining 
finger  and  the  infiltration.  The  hardness  is  so  marked  in  some  cases  as  to  give  the 
impression  of  a  cartilaginous  growth  from  the  pelvic  wall.  The  uterine  attachment 
of  the  mass  is  low,  principally  about  the  cervix.  The  outer  extremity  extends  to 
the  pelvic  wall,  where  it  is  intimately  attached  over  a  broad  surface  (Fig.  384). 

9.  Small  Abscess  from  Cellulitis, with  wall  so  thick  that  no  fluctuation  is  obtained. 
There  is  a  point  of  marked  tenderness,  with  some  fever,  and  a  mass  or  induration 
presenting  the  characteristics  of  cellulitis. 

10.  Scar  Tissue  from  former  Cellulitis.  As  explained  elsewhere,  uncompHcated 
cellulitis,  like  other  forms  of  lymphangitis,  runs  its  course  and  ends  in  resolution  or 
abscess  formation  with  discharge  of  the  pus.  In  either  case  the  accompanying  in- 
flammatory infiltration  eventuates  in  the  formation  of  new  connective  tissue  which 
contracts  like  other  scar  tissue,  causing  persistent  induration  and  fixation  of  tissues 
in  the  affected  area.  There  is  not  much  tenderness  from  the  scar  tissue  itself,  but 
the  resulting  compression  or  constriction  of  nerves  and  interference  with  the  circu- 
lation by  distortion,  may  exceptionally  cause  persistent  tenderness  and  pain. 

1 1 .  Scar  Tissue  from  Laceration  in  Labor.  Not  infrequently  tears  of  the  cervix 
are  so  extensive  that  they  involve  the  vaginal  wall  and  the  parametrium,  giving 
scars  that  may  be  felt  beside  the  cervix.  The  induration  may  be  linear  or  wide- 
spread. The  fixation  of  the  cervix  may  be  slight  or  marked,  depending  on  the 
amount  and  situation  of   the  scar  tissue.     Usually  there  is  not   much  tenderness. 

12.  Malignant  Infiltration  of  the  parametrium,  extending  from  the  cervix  uteri 
or  the  bladder  or  the  rectum.  The  induration  is  firm  and  is  situated  immediately 
beneath  the  vaginal  wall  and  usually  follows  approximately  the  outline  of  the  con- 
nective area.  Ordinarily  there  is  not  much  tenderness,  unless  there  is  complicating 
inflammation.  The  amount  of  fixation  of  the  cervix  depends  on  the  extent  of  the 
infiltration. 

13.  Fibroid  of  Uterus,  growing  into  right  broad  ligament.  The  mass  projects  out 
from  the  side  of  the  uterus,  has  a  rounded  well-defined  outer  border  and  is  firm  and 
not  tender.  The  mass  is  fixed  by  a  broad  attachment  to  the  side  of  the  uterus  but 
the  uterus  and  mass  together  are  movable  in  the  pelvis,  unless  the  mass  is  so  large 
that  it  extends  to  the   pelvic  wall  or  there  is  complicating  inflammatory  fixation. 

14.  Affection  of  Right  Ureter.  A  mass  about  the  ureter  may  be  caused  by  in- 
flammation in  and  around  the  ureter.  The  inflammation  may  be  due  to  a  stone 
lodged  in  the  ureter  or  to  tubercular  ureteritis  or  to  an  ascending  pus  infection. 
The  mass  is  situated  in  the  course  of  the  ureter,  is  small  at  first  and  may  give  the 
impression  of  a  small  nodule  like  an  enlarged  gland  in  the  tissues.  It  is  firm, 
very  tender,  fixed,  but  not  intimately  attached  to  any  of  the  adjacent  organs  until 
extensive  infiltration  has  formed.  Fig.  385  shows  a  mass  from  the  right  ureter. 
A  mass  from  the  ureter  is  accompanied  by  bladder  irritability  and  urinary  abnor- 
malities. 

15.  Solid  Tumor  of  Ovary  or  Tube,  bound  down  by  adhesions  and  forced  to  grow 
towards  the  cervix.  The  mass  would  necessarily  become  of  considerable  size  be- 
fore reaching  that  region.  It  is  approximately  spherical,  though  of  somewhat  irreg- 
ular outline.     It  is  firm  and  usually  somewhat  tender  because  of  the  accompanying 


FLUID  MAS«  TO  RIGHT  OF  CERVIX  UTERI 


259 


inflammfition,  but  not  as  tender  as  an  inflammatory  mass  of  the  same  size  would  be. 
It  is  fixed  in  the  pelvis  and  attached  to  all  surrounding  structures.  The  uterus  is 
usually  pushed  far  to  the  opposite  side,  but  the  history  does  not  show  the  .severe 
disturbance  that  would  necessarily  accompany  a  purely  inflammatory  mass  of  like 
size. 


Fig.  385.  Mass  in  'Right  Ureter.  It  is  a  Calculus  of  enormous 
size,  situated  in  the  ureter  and  extending  into  the  bladder-wall;  a, 
calculus;  b,  upper  part  of  right  ureter  (thickened);  c,  left  ureter; 
d,  sigmoid;  e,  left  Fallopian  tube;  f,  bladder  pushed  to  one  side. 
(Bovfee — Practice  of  Gynecology.) 


B.  Mass  Contains  Fluid  (Fluctuation  May  be  Obtained). 

1 .  Pelvic  Abscess  (Fig.  386)  from  salpingitis,  with  secondary  involvement  of  con- 
nective tissue,  or  from  primary  cellulitis,  or  from  suppuration  in  a  fibroid  tumor  or  in 
a  cyst  or  in  a  hematoma  in  this  situation.  The  mass  usually  fills  in  all  the  lower 
part  of  that  side  of  the  pelvis,  and  is  surrounded  by  infiltration  which  shades  off 
gradually  into  the  surrounding  tissues.  The  area  of  fluctuation  is  surrounded 
by  induration.  There  is  marked  tenderness  at  the  point  of  fluctuation,  which 
diminishes  usually  as  the  periphery  of  the  mass  is  reached.  There  is  fixation  of 
all  the  involved  tissues  and  of  the  adjacent  organs,  including  the  uterus.  The  his- 
tory and  the  findings  elsewhere  in  the  pelvis,  indicate  the  seat  of  the  primary  in- 
riammation. 

2.  Pelvic  Hematoma  (Fig.  387).     This  usually  comes  from  a  tubal  pregnancy, 


260 


GYNECOLOGIC  DIAGNOSIS 


which  has  ruptured  between  the  layers  of  the  broad  Hgament.  The  induration  runs 
down  close  around  the  cervix,  and  may  be  small  or  may  fill  all  that  side  of  the  pelvis 
extending  up  to  the  top  of  the  broad  hga- 
ment. It  has  a  general  rounded  outline; 
much  more  so  generally  than  an  inflam- 
matory infiltration  in  the  connective  tis- 
sue;  though  it  is  limited  anteriorly  and 
posteriorly  by  the  separated  peritoneal 
layers  of  the  broad  ligament. 

It  is  largely  fluid  and  there  is  distinct 
fluctuation  over  a  considerable  area,  as  in 
a  cyst.  Also,  there  is  not  so  much  sur- 
rounding induration  as  in  an  abscess, 
though  usually  considerably  more  than  in 
a  cyst.  The  tenderness  is  not  nearly  so 
marked  as  in  a  collection  of  blood  in  the 
peritoneal  cavity.     Of  course  the  tender- 


fig.  386.  Mass  beside  Uterus,  formed  by  Ab- 
cess  in  broad  ligament.  (Montgomerj' — Practi- 
cal Gjinecology.) 


Fig.  .387.     Hematoma  of  Right  Broad  Ligament. 
Practical  Oynecologt/.) 


(Montgomery- 


ness  varies  somewhat,  being 
more  marked  when  the  hemorr- 
hage is  recent  and  extensive,  in 
which  case  it  may  be  very 
marked.  Ordinarily  the  ten- 
derness from  a  hematoma  is 
not  nearly  so  marked  as  tender- 
ness from  an  abscess.  There  is 
fixation  of  themassinthe  situa- 
tion in  which  it  is  found,  and,  if 
extensive,  it  fixes  the  uterus  to 
the  pelvic  wall.  The  history 
and  the  findings  elsewhere  will 
show  the  cause  of  the  trouble. 


3.  Hydrosalpinx  coming  low  in  the 
pelvis.  The  cystic  mass  runs  up  into  the 
tubal  region.  It  is  somewhat  elongated 
and  sausage-shaped  and  extends  from  the 
upper  angle  of  the  uterus  to  the  pelvic 
wall.  It  fluctuates  freely  and  gives  the 
impression  of  a  thin-walled  cyst.  Fre- 
quently some  induration  from  exudate  or 
adhesions,  may  be  felt.  It  is  iiot  tender 
ordinarily.  It  is  somewhat  movable, 
though  not  as  much  so  as  a  small  pedicu- 
lated  ovarian  tumor.  It  is  attached  to 
the  uterus  and  to  the  pelvic  wall  and  along 
the  upper  part  of  the  broad  ligament. 

4.  Parovarian   Cyst    (Fig.  388).     It   is 


Fife.  388.  A  Parovarian  Cyst,  forming  a  large Ma-^ 
and  displacing  the  uterus.  (Ashton— Practtce  vf 
Oijnecology.) 


OTHER  FLUID  MASSES  BESIDE  CERVIX 


261 


situated  near  the  center  of  the  broad  Ugament  and,  if  as  large  as  an  orange,  it  begins 
to  come  down  about  the  cervix  just  beneath  the  vaginal  wall.  It  is  approximately 
spherical,  though  somewhat  irregular  in  shape.     It  fluctuates  freely  throughout 

and  the  fluid  seems  very  close  to  the 
examining  fingers.  There  is  no  tender- 
ness, unless  complicated  l)y  inflammation 
or  neuritis  or  other  painful  affection. 

It  is  fixed,  as  a  rule,  but  not  firmly. 
The  peritoneal  layers  of  the  broad  liga- 
ment stretch  sufficiently  to  permit  con- 
siderable movement  in  some  cases,  especi- 
ally later,  when  the  cyst  has  gotten  so  large 
that  it  rises  out  of  the  pelvis.  The  uterus 
is  displaced  to  the  opposite  side,  and  the 
cyst  is  attached  to  it  and  to  the  pelvic 
wall,  but  not  intimately  as  a  rule.  If  in- 
flammation takes  place  about  the  cyst 
then  there  is  marked  fixation  and  attach- 


Fig.  389.     An  Ovarian  Cyst  growing  in  beside 
the  uterus.     (Montgomery — Practical  Gynecology.) 


ment  to  all  adjacent  organs,  and  the 
cyst  as  it  grov\^s  may  elongate  the 
body  of  the  uterus. 

5.  Ovarian  Cyst  growing  toward 
the  cervix  (Fig.  389).  An  ovarian 
cyst  which  has  been  fixed  in  the 
pelvis  by  inflammation  may  grow 
in  this  direction.  It  presents  the 
same  characteristics  as  a  parovarian 
cyst  complicated  by  inflammation, 
except  that  fluctuation  is  not  so 
uniform  throughout  the  mass. 
There  may  be  firm  portions  repre- 
senting thick  septa  or  small  areolar 
cysts. 

6.  Cystic  Fibroid.  This  presents 
the  ordinary  characteristics  of  a  fib- 
roid, except  that  there  is  a  point  of 
fluctuation  and  there  may  be  some 
tenderness. 

7.  Uterus  containing  fluid  and 
displaced  to  one  side.    This  fluid  in 

the  uterus  may  be  due  to  pregnancy,  normal  or  abnormal,  or  to  a  cystic   fibroid  or 
topus  in  the  uterus  or  to  blood  in  the  uterus. 

8.  Rudimentary  Horn  of  Uterus,  containing  blood  (Fig.  390)  or  other  fluid.    There 
may  be  pregnancy  in  such  a  horn  (Fig.  408). 

9.  Vaginal  Cyst.     Vaginal  cysts  may  come  from  remnants  of  the  WolfTan  duct  or 
from  aberrant  gland  structures  in  the  vaginal  wall.     They  protrude  into  the  va- 


Fig.  390. 
the  Uterus. 


VULVA. 


Hematometra  in  a  Rudimentary  Horn  of 
(Montgomery — Practical  Gynecology .) 


262 


GYNECOLOGIC  DIAGNOSIS 


gina  more  or  less,  are  small  and  rounded,  have  fluctuation  throughout  with  a  thin 
wall  and  are  not  tender  unless  complicated.  They  are  fixed  in  the  lower  part  of  the 
pelvis  and  lie  just  beneath  the  vaginal  wall,  to  which  they  are  closely  attached. 

10.  Ureter  Greatly  Dilated.  The  fluid  in  the  dilated  ureter  may  be  urine  (hydro- 
ureter)  or  pus  (pyo-ureter) .  The  upper  part  of  the  ureter  and  the  kidney  is  usually 
dilated  also  (hydronephrosis,  pyonephrosis).     A  fluctuating  swelling  is  found  in 


Fig.  391.  Thickened  Tube  and  Ovary  prolapsed 
into  tne  cul-de-sac  behind  the  uterus.  (Montgomery 
— Practical  Gynecology.) 


Fig.  392.  A  Fibroid  Tumor,  forming  a  Mass 
behind  the  uterus.  (Montgomery— Prac<jcai 
Gynecology.) 


Fig.  393.  A  Retroflexed  Uterus  and  a  Fibroid, 
forming  a  Mass  behind  the  cervix.  (Montgomery — 
Practical  Gynecology.) 


the  region  of  the  ureter,  accompanied  by  symptoms  of  bladder  irritation  and  uri- 
nary evidences  of  .disease.  The  retained  urine  may  be  discharged  at  times  through 
the  bladder.  The  swelling  then  largely  disappears,  to  reappear  when  the  obstruc- 
tion again  occurs  and  the  sac  refills.  A  careful  investigation  as  to  the  amount  and 
character  of  the  urine  discharged  with  the  variation  in  the  size  of  the  mass,  is  an 
important  step  in  the  diagnosis  of  such  a  mass. 


SOLID  iMASS  BEHIND  CERVIX  UTEUI  263 


MASS  LOW  in  Pelvis,  and  to  LEFT  of  Cervix. 

A.  Mass  or  Induration  Firm  (No  fluid  felt).     Same  as  on  right  side. 

B.  Mass  contains  Fluid  (Fluctuation  obtained).     Same  as  on  right  side. 


MASS  LOW  and  BEHIND  Cervix. 

A.  Mass  or  Induration  Firm. 

1.  Body  of  Uterus  Displaced  backward  to  the  3rd  degree  (Fig.  71).  Any  of  the 
various  solid  conditions  of  the  uterus  previously  mentioned  may  be  present. 

2.  Salpingitis  with  Exudate  extending  into  the  cul-de-sac. 

3.  Salpingitis  with  Prolapse  of  the  thickened  tube  into  the  cul-de-sac  (Fig.  39L) 
The  prolapsed  tube  may  be  movable  or  adherent. 

4.  Salpingitis  with  Secondary  Infiltration  of  the  connective  tissue  back  of  the 
•iter  us. 

5.  Oophoritis  with  Prolapse  of  the  ovary.  The  prolapsed  ovary  may  be  movable 
or  adherent.  The  characteristic  palpation  signs  of  a  prolapsed  ovary  have  already 
been  given. 

6.  Small  Abscess  behind  the  cervix,  from  any  of  the  above  conditions  and  with 
such  a  thick  wall  that  no  fluctuation  is  obtained. 

7.  Adhesions  behind  the  cervix,  from  any  of  the  above  affections. 

8.  Cellulitis.  For  the  characteristic  palpation  signs  of  cellulitis,  see  under  "  mass 
to  right  of  cervix." 

9.  Small  Abscess  from  Cellulitis,  with  wall  so  thick  that  no  fluctuation  is  obtained. 

10.  Scar  Tissue  from  Former  Cellulitis.  This  is  not  nearly  so  frequent  in  this 
region  as  peritoneal  adhesions. 

11.  Scar  Tissue  from  Laceration  in  Labor.  This  is  found  occasionally,  though  it 
is  rare  in  this  situation.     Most  of  the  deep  lacerations  extend  laterally. 

12.  Malignant  Infiltration  from  cancer  of  cervix  uteri  or  from  cancer  of  the 
rectum  or  from  cancer  of  the  bladder. 

13.  Fibroid  of  the  Uterus  growing  posteriorly  from  the  cervix  or  lower  part  of  the 
corpus  uteri  (Figs.  392,  393). 

14.  Affection  of  Ureter  with  exudate  extending  back  of  the  uterus.  The  differ- 
ential diagnostic  points  of  a  ureteral  mass  have  already  been  given  (page  258). 

15.  Solid  Tumor  of  Ovary  or  Tube,  forced  to  grow  into  the  cul-de-sac. 

16.  Fecal  Mass  in  Rectum.  Along  the  lower  part  of  the  posterior  vaginal  wall 
such  masses  cause  no  trouble  in  diagnosis,  but  in  the  region  of  the  cul-de-sac  they 
may  lead  to  a  mistake.  The  characteristics  of  such  a  fecal  mass  are  that  it  is  situ- 
ated in  the  course  of  the  rectum,  that  it  is  not  particularly  tender,  that  it  is  of  putty- 
like consistency  and  may  be  indented  (the  dent  remaining)  and  that  it  may  be 
moved  along  to  another  position  in  the  canal.  If  there  is  still  doubt,  direct  the 
patient  to  take  a  purgative  to  give  a  good  bowel  movement  and  the  next  day  an 
enema  to  clear  out  the  large  bowel,  and  then  return  for  another  examination. 


264 


GYNECOLOGIC  DIAGNOSIS 


17.  Tumor  of  Rectum.  The  mass  is  in  the  wall  of  the  rectum  and  there  are  usually 
symptoms  of  rectal  irritation,  "uith  the  passage  of  blood  and  mucus. 

18.  An  Abdominal  Organ  Prolapsed  into  the  cul-de-sac.  A  wandering  kidney  or 
spleen  ma}'  be  found  in  this  situation.  It  may  be  movable  or  fixed.  It  presents 
somewhat  the  characteristics  of  the  organ  involved,  i.  e.,  it  has  about  the  size,  shape, 
consistency  and  tenderness.  If  movable  it  may  be  pushed  back  into  the  normal 
situation  of  the  organ.  An  examination  in  the  Trendelenburg  posture  may  aid 
very  materially  in  this.  The  knee-chest  posture,  taken  for  a  few  seconds,  may  cause 
the  organ  to  return  to  the  abdominal  cavity.  Careful  examination  may  show  the 
organ  absent  from  its  normal  position.  If  it  is  the  kidney,  there  may  or  may  not  be 
bladder  symptoms  or  urinary  abnormahties. 


Fig.  394.     An  Abscess  behind  the  uterus. 
gomery — Practical  Gynecology.) 


(Mont-  Fig.  .39.5.    A  Blood  Mass   filling    the    pehds   and 

running  do^n  behind  the  uterus.     (Montgomery— 
Practical  Gynecology.) 


B.  Mass,  Behind  Cervix,  Contains  Fluid. 


1.  Pelvic  Abscess  (Fig.  394)  from  salpingitis,  from  oophoritis,  from  cellulitis, 
from  hematocele  or  hematoma,  from  a  suppurating  sohd  tumor  or  from  a  suppu- 
rating cyst. 

2.  Intra-peritoneal  Hemorrhage  (Fig.  395).  This  usually  comes  from  tubal 
pregnancy,  with  rupture  of  the  wall  of  the  tube  or  abortion  from  the  end  of  the  tube 
into  the  peritoneal  cavity.  Blood  in  the  peritoneal  cavity  presents  one  of  three 
conditions,  as  follows: 

a.  The  blood  may  be  free  in  the  cavity.  This,  like  ascites,  does  not  give  rise  to 
any  distinct  mass  or  induration,  hence  does  not  require  consideration  here.  The 
characteristics  of  this  condition  are  given  in  chapter  xi. 

b.  Clots  and  fibrinous  exudate  forming  a  mass  about  the  affected  tube  and  ex- 
tending from  the  tube  into  the  cul-de-sac.  This  forms  a  mass.  If  there  is  a  large 
amount  of  plastic  exudate,  the  mass  is  rather  firm  and  with  definite  outlines.  If 
the  mass  is  made  up  principally  of  recent  blood  clots,  it  is  soft  and  the  outlines  in- 


FLUID  MASS  BEHIND  CERVIX   UTERI 


265 


distinct.  This  condition  is  found  in  those  cases  where  there  are  repeated  sUght 
hemorrhages.  This  is  a  dangerous  state  of  affairs  for,  though  the  bleecUng  has 
stopped  temporarily,  any  exertion,  or  a  disturbance  of  the  clots  by  an  examination, 
may  start  a  severe  hemorrhage. 

c.  Some  blood  has  run  into  the  cul-de-sac 
and  a  firm  roof  of  fibrinous  exudate  has 
formed  above  it,  shutting  it  off  completely 
from  the  general  peritoneal  cavity.  This 
condition  is  called  pelvic  "hematocele", 
and  represents  the  least  dangerous  condi- 
tion of  intra-peritoneal  hemorrhage. 

The  physical  signs  of  intraperitoneal 
clotted  blood  and  exudate  are  practically 
the  same  as  those  of  inflammatory  exudate, 
with  the  exception  of  the  temperature. 
There  is  usually  but  little  fever  after  the 
first  forty-eight  hours,  and  in  many  cases 
not  much  at  any  time.  Of  course,  if  sup- 
puration comes  on  later  in  the  blood  mass 
then  the  ordinary  signs  of  suppuration  ap- 
pear, including   fever.      The    diagnosis    of 


Fig.  396.    An  Ovarian  Cyst  lying  back  of  the 
uterus.      (Ashton— Practice  of  Gynecology.) 


a  blood  mass,  rather  than  an 
inflammatory  mass,  must  rest 
largely  upon  the  absence  fo 
decided  fever  in  the  presence 
of  acute  symptoms  and  upon 
certain  points  in  the  history 
and  progress,  indicating  a  tubal 
pregnancy.  These  points  are 
given  under  tubal  pregnancy 
in  chapter  xi. 

3.  Hydrosalphinx  low  in  the 
cul-de-sac.  The  prolapsed  and 
chstended  tube  may  be  mov- 
able or  adherent. 

4.  Parovarian  Cyst  pushing 
back  behind  cervix  and  filling 
the  posterior  part  of  the  pelvis. 

5.  Ovarian  Cyst  in  cul-de-sac 
(Figs.  396,  397) .  A  small  ova- 
rian cyst  may  easily  drop  into 
the  cul-de-sac.     If  it  becomes 

adherent   it   will   remain    there,  choking   the   pelvis    as   it    enlarges. 

6.  Cystic  Fibroid.     This  presents  the  characteristics  of  a  fibroid,  with  fluctuation 
and  some  tenderness  added. 


Fig.  397.     Showing  the  Method  of  Testing  the  Mobility  of 
such  a  Mass,     (Ashton— Practice  of  Gynecology.) 


266 


GYNECOLOGIC  DIAGNOSIS 


D0uGLP,-)3  CUL  DE  ;/5C 


7.  Uterus  Containing  Fluid  and  displaced  backward.     The  fluid  in  the  uterus  may 
be  due  to  pregnancy  or  to  a  cystic  fibroid  in  the  wall  or  to  pus  or  to  blood. 

8.  Small  Cyst  of  Some  Abdominal  Structure  lying  in  cul-de-sac.     Such  a  cyst  may 
come  from  the  omentum,  from  the  mesentery  or  form  a  prolapsed  kidney  or  spleen. 

9.  Ureter  Greatly  Dilated  (hydro-ureter  or  pyo-ureter)  and  filling  in  back  of  the 

MASS  LOW  and  IN  FRONT  of  Cervix. 
A.  Mass  or  Induration  Firm. 

1 .  Uterus  Displaced  Forward.     There  may  be  any  of  the  solid  conditions  of  the 
uterus  already  mentioned. 

2.  Fibroid  Tumor  of  Uterus  (Fig.  398). 

3.  Malignant  Disease  of  cervix  extending 
forward  or  of  the  urethra  extending  back- 
ward or  of  the  vagina,  may  give  induration 
in  front  of  the  cervix. 

4.  Cellulitis,  between  uterus  and  bladder. 
The  characteristics  of  an  induration  from 
cellulitis  have  already  been  given  (page  258.) 

5.  Bladder  Disease.  This  may  be  a  tumor 
(Fig.  399)  or  tuberculosis  (Fig.  400)  or 
chronic  inflammation. 

B.  Mass,  in  Front  of  Cervix,  Contains 

Fluid. 
1.  Bladder  Distended  with  Urine  (Fig.  344). 
Whenever,  in  making  a  bimanual  examina- 


\ 


Fig.  398.  A  Fibroid  forming  a  Mass  in 
front  of  the  uterus.  (Thomas  and  Munde — 
Diseases  of  Women.) 


Fig.  :J99.    A  Tumor  of  the  Bladder.    ( Ashton— /'r«c«ce  of  Gynecology.) 


tion,  a  cystic  mass  is  felt 
in  front  of  the  uterus, 
catheterize  the  patient  if 
necessary  to  eliminate  a 
full  bladder. 

2.  Uterus  Containing 
Fluid.  This  is  usually  due 
to  pregnancy,  though  it 
may  rarely  be  due  to  pyo- 
metra  or  hematometra. 

3.  Pelvic  Abscess.  A 
pelvic  abscess  in  this  sit- 
uation is  usually  due  to  a 
cellulitis. 

4.  Pelvic  Hematoma. 
Occasionally  a  hematoma 
from  tubal  pregnancy  will 
dissect  in  between  the  ute- 
rus and  bladder  and  give  a 


MASS  IN  FRONT  OF  UTERUS 


267 


Fig.  400.     Tuberculosis  of  the  Bladder,  forming  a  Mass  in  front  of 
the  uterus.     (Dudley — Practice  of  Gynecology.) 


fluctuating  mass  in  this  region, 
but  this  is  very  rare. 

5.  Vaginal  Cyst.  This  pro- 
iects  into  the  vagina,  and  the 
fluid  appears  to  be  just  beneath 
the  vaginal  wall.  Its  point  of 
attachment  is  very  low,  ap- 
parently in  the  vesico-vaginal 
septum. 

6.  Parovarian  Cyst.  Such  a 
cyst  may  grow  in  between  the 
uterus  and  the  bladder. 

7.  Cystic  Fibroid.  A  fibroid 
growing  from  the  anterior  part 

of   the   cervix  may  displace  the  bladder  upward  and  give  a  mass  just  in  front  of 
the  cervix. 

MASS  LOW   and   FILLING   Pelvis. 

A.  Mass  or    Induration  Firm. 

1.  Extensive  Inflammatory  Exudate  or  infiltration,  from  salpingitis,  oophoritis, 
peritonitis  or  cellulitis  (Fig.  401).      This  extensive  inflammatory  exudate  fixes  all 


Fig.  401.  Inflammatory  Exudate  filling  the  pelvis  and  form- 
ing a  firm  roof  above  the  examining  fingers.  The  resisting 
"roof"  usually  follows  about  the  line  indicated  in  Fig.  402. 


268 


GYNECOLOGIC  DIAGNOSIS 


the  organs,  as  though  plaster  of 
Paris  had  been  run  in  around  them 
and  had  hardened  there.  On  mak- 
ing the  vaginal  examination  there 
iS  found  a  firm  roof  above  the  ex- 
amining fingers,  on  approximately 
the  plane  indicated  in  Fig.  402. 

2.  Extensive  Bleeding  in  the  pel- 
vis, in  the  form  of  hematoma  or 
hematocele  or  blood  clots  without 
hmiting  roof  of  exudate. 

3.  Large  Fibroid  in  lower  part  of 
uterus.  This  may  be  any  one  of 
the  various  forms  of  fibromyoma. 

4.  Malignant  Disease  of  cervix  or 


Fig.  402.  Indicating  the  general  direction  of  the 
lower  surface  of  the  "roof  of  exudate"  in  most  cases. 
(Thomas  and  Munde— Diseases  of  Women.) 


corpus  uteri  or  of  bladder  or  of  rec- 
tum. There  may  be  malignant 
disease  and  fibroid. 

5.  Tumor  from  Pelvic  Wall  (Fig. 
403). 

B.  Mass,  Low  and  Filling  Pelvis, 
Contains  Fluid. 

1.  Uterus  Pregnant.  The  enlarged 
and  fluctuating  uterus  may  be  in 
normal  position  or  in  displacement 
(Fig.  350).  It  may  be  regular  in 
shape  or  very  irregular  (Figs.  368, 
369,370). 

2.  Parovarian  Cyst.  This  may 
grow  low  in  the  pelvis  and  fill  it, 
displacing  the  organs  in  various  di- 
rections. 

3.  Ovarian  Cyst.   An  ovarian  cyst 
bound  down  by  adhesions,  may  fill 
the  pelvis  and  extend  to  the  lower 
part  of  it.    There  may  be  some  com- 
plicating  condition,    for    example,    an  ovarian   cyst  and    pregnancy    (Fig.   404). 

4.  Pelvic  Abscess  with  .extensive  exudate  or  infiltration  may  fill  the  pelvis.  The 
point  of  fluctuation- is  usually  l^ehind  the  cervix.  Most  of  the  mass  is  firm,  and 
there  is  the  firm  inflammatory  roof  previously  mentioned. 

5.  Collection  of  Blood  in  pelvis.  This  may  be  present  in  the  form  of  hematoma 
or  hematocele.  In  addition  to  an  area  of  fluctuation,  there  is  usually  the  firm  rooi 
due  to  accompanying  infiltration  and  exudate. 


Fig.  403.     Pelvis   filled   with  a  Bony  Tumor  from  the 
pelvic  wall.     (A.  Martin— ^<tes  of  Gynecology. ^ 


MASS  HIGH  IN   PELVIS  OR  LOWER  ABDOMEN 


269 


Fig.  404.     Pelvis  and  Lower  Abdomen  filled  with  a  Mass  composed  of  a 
Pregnant  Uterus  and  an  Ovarian  Cyst.    (Williams,  after  Bumm — Obstetrics.) 


MASS  HIGH,  in    Pelvis  or   Lower  Abdomen,  RIGHT  Side. 

A.  Mass  or  Induration   Firm. 

1 .  Uterus  Displaced.     Any  one  of  the  various  solid  conditions  of  the  uterus  previ- 
ously mentioned  may  form  a  mass  in  the  center  of  the  pelvis  or  to  one  side. 
•     2.  Salpingitis.     There  may  be  simply  a  thickened  tube  (Fig.  405)  or  a  large  mass 
of  exudate. 


Fig.  405.     Salpingitis  Nodosa.      (Thomas  and  Munde— Diseases  of 
Women.) 


o.  Pyosalpinx^with  small  amount  of  pus  and  such  a  thick  wall  that  no  fluctuation 
is  obtained.     There  may  be  very  little  peri-tubal  exudate  or  a  great  deal. 


270 


GYNECOLOGIC  DIAGNOSIS 


4.  Oophoritis,  -^-ithout  any  cyst  large  enough  to  give  fluctuation.    There  may  be 
little  or  no  exudate  or  there  may  be  a  large  amount  of  exudate. 

5.  Adhesions,  from  any  of  the  above  conditions.     The  adhesions  may  besUght  or 
extensive. 


Fig.  406.     Tlirombosis  of  Veins  of  the  broad  ligament.      (Schaeffer — Hand- 
Atlas  of  Gynecology.) 


6.  Cellulitis,  in  upper  part  of  broad  ligament,  or  resulting  scar  tissue  from  same. 

7.  Thrombosis  of  Veins  of  Broad  Ligament  (Fig.  406).     This  condition,  though 
rare,  probably  occurs  more  frequently  than  is  generally  supposed. 


•^•L/ 


•*^- 


^•^f 


Fig.  407.     Tubal  Pregnancy  in  the  Right  side.     (.Dickinson— A mericayi 
Text-hook  of  Obstetrics.) 


8.  Solid  Tumor  of  Ovary  or  Tube.     This  may  be  small  or  large,  movable  or  ad- 
herent. 

9.  Extra-uterine  Pregnancy.     This    may    be    tulxal    pregnancy    (Fig.    407)    or 


SOLID  MASSES  ON  RIGHT  SIDE 


271 


pregnancy  in  a  riulimentaiy  horn  of  the  uterus  (Figs.  408,  409).     For  the  special 
evidences  of  extra-uterine  pregnancy  see  chapter  xi.     Tubal  pregnancy,  with  its 
resulting  hemorrhage  and  plastic  exudate  and  adhesions  binding  together  the  vaii- 
ous    structures   and    giving   a    tender 
mass  in  the    tubo-ovarian  region,    is 
most  frequently  mistaken  for  an  ordi- 
nary inflammatory  mass. 

10.  Pelvic  Tuberculosis.  The  mass 
presents  the  characteristics  of  a  chronic 
inflammatory  mass,  which  in  fact  it  is. 
The  fact  that  the  inflammation  is  tuber- 
cular must  be  determined  by  other  fea- 
tures of  the  case  than,  the  pelvic  palpa- 
tion. For  these  other  diagnostic  points , 
see  pelvic  tul^erculosis  in  chapter  xi, 

11.  Fibroid  Tumor  of  Uterus.  This 
is  subperitoneal  and  may  be  pedicu- 
lated  (Fig.  375)  or  sessile  (Fig.  376). 

12.  Appendicitis  with  Exudate.  The  mass  is  situated  about  the  appendix  and 
the  history  points  to  bowel  trouble,  rather  than  to  tubal  trouble.  In  some  cases 
the  appendix  extends  into  the  tubal  region,  causing  more  or  less  confusion  in  diag- 
nosis. The  various  situations  which  the  appendix  has  been  found  to  occupy  in  dif- 
ferent   cases,  without  change  of  the  position  of  the  caecum,  are  shown  in  Fig.  410. 


Fig.  408.  Pregnancy  in  the  Rudimentary  Horn  of 
a  malformed  uterus.  (Jay's  Case — Saunder's  Year 
Book,  Tfj04.) 


Fig.  409.  Pregnancy  in  a  Rudimentary  Horn  of  the  Uterus.  As  there  is  no  communicating  cavity 
between  the  uterine  cavity  and  site  of  the  pregnancy  in  the  rudimentary  horn,  the  spermatozoa 
evidently  came  by  way  of  the  opposite  tube,  as  indicated  by  the  small  arrows.  (KeWy— Operative 
Gynecology.) 


272 


GYNECOLOGIC  DIAGNOSIS 


'^W ' '' 

tbfhind    cecum. 


esiaL    to  cecum  over  Ueum., 
11.       n        1       under       h 


behind  ileo-ceca^'--%., 
Jimctioa         '"■ 


in  iliac    fossa 


ilong    iliac  vessels 


Fi>;.  410.     Diagram   showing  various  positions    in    wiiich  the    Appendix    vermiformis 
may  lie,   with  the  caecum  in  tne  usual  place.      (Kelly— Diseases  of  the  Appendix.) 


In  cases  where  the  caecum  varies  from  the 
usual  position,  the  appendix  may  be  still 
farther  from  its  normal  position,  as  indicated  in 
Fig.  411.  In  a  case  of  appendicitis  there  may 
be  a  point  of  pain  and  tenderness  elsewhere  in 
the  abdomen,  in  addition  to  that  in  the  appen- 
dix region.  Then  immediately  arises  the  ques- 
tion, "Do  any  of  these  additional  areas  of  ten- 
derness represent  an  additional  lesion  or  is  the 
pain  and  tendeigfiess  simply  reflex  from  the  in- 
flamed appendix?"  My  friend.  Dr.  Leonidas 
Kirby,of  Harrison,  Arkansas,  recently  called 
my  attention  to  the  following  method  of 
identifying  the  reflex  areas  of  tenderness.  With 
the  patient's  knees  drawn  up  to  relax  the  ab- 
dominal muscles  as  in  regular  abdominal  pal- 
pation, note  the  areas  of  tenderness.  Then 
make  steady  pressure  exactly  over  thfe  appen- 
dix sufficient  to  cause  decided  pain  and,  while 


Fig.  411.  Diagram  showing  various 
positions  which  the  Caecum  and  Appendix 
may  occupy,  in  cases  where  the  caecum  is 
displaced.  (Kelly — Diseases  of  the  Ap- 
pendix.) 


MASSES  FROM  INTESTINAL  TRACT 


273 


maintaining  this  pressure  over  the  appendix,  i);il[):i((Mvith  the  other  hand  the  areas 
\vh  ch  are  tender.  When  the  tenderness  in  the  otlier  areas  is  rcHex,  it  disappears 
as  long  as  the  pressure  over  the  appendix  is  maintained,  to  reap])ear  as  soon  as  the 
pressure  over  the  appencUx  ceases.  Dr.  Kirby  has  found  this  simple  expedient 
very  helpful  in  a  considerable  number  of  tloubtful  cases. 

13.  Fecal  Mass,  in  caecum  and  extending  along  the  ascending  colon. 

14.  Tumor  of  Caecum.     This  is  usually  malignant.     It  presents  chronic  irrita- 
tion in  the  caecal  region,  generally  leading  to  a  diagnosis  of  chronic  appendicitis. 

There  are  exacerbations  of  trouble  at  times,  due  apparently  to  irritation   in  the 
caecum  from  retained  fecal  material.     In  some   cases  there  is  a  swelling  in  this 


Fig.  412.  Movable  Kidney,  showing  the  outline  of  the  displaced  kid- 
ney as  determined  by  palpation.  Notice  that  the  kidney  comes  well  be- 
low a  line  drawn  from  the  umbilicus  to  the  right  anterior  superior  iliac  spine 
(marked  by  a  cross) . 


region,  that  comes  and  goes.  It  is  most  marked  usually  during  the  days  of  pain 
and  disappears  largely  when  the  bowels  are  well  opened.  Later  a  permanent  mass 
appears,  though  it  may  vary  consideral:)ly  in  size  at  different  times,  due  to  the  vary- 
ing amount  of  fecal  material  in  the  caecum.  This  same  history  may  be  present  at 
times  in  chronic  caecitis  without  a  tumor,  l^ut  in  such  a  case  of  course  there  is  no 
permanent  tumor,  unless  there  is  some  complicating  inflammatory  trouble  around 
the  caecum. 

15.  Intussusception.     The  mass  extends  along  the  caecum  and  ascending  colon. 


274 


GYNECOLOGIC  DIAGNOSIS 


There  is  the  history  of  intestinal  obstruction,  the  passage  of  bloody  mucus  from  the 
bowel  and  the  rectal  tenesmus.     It  is  most  frequent  in  children. 

16.  Displaced  Kidney  (Fig.  412).     The  mass  has  approximately  the  size  and[ 


Fig.  413.  Palpation  of  a  Movable  Kidney,  with  the 
patient  on  her  back.  First  step.  The  loin  is  grasped 
as  here  shown,  to  prevent  the  displaced  kidney  from 
slipping  unnoticed  back  into  its  place  at  the  beginning 
of  palpation. 


Fig.  414.  Palpation  of  a  Movable  Kidney,  witi; 
patient  on  her  back.  Second  step.  Palpating  the  kid- 
ney with  the  right  hand,  while  it  is  lield  in  displacement 
with  the  left  hand. 


VARIOU8  MASSES  WITIK  )l  'l'   M,1J(  TUATION  275 

shape  of  the  Icklnoy  iind  is  louder  wIumi  pressed  upon.  Pressure  usually  causes  a 
desire  to  urinate,  and  it  may  cause  pain  running  along  the  ureter  to  the  bladder. 
The  prolapsed  kidney  is  usually  somewhat  enlarged.  Unless  adherent  in  its  mal- 
position, it  may  ])e  returned  to  its  ])ed  in  the  loin.  This  facility  with  which  the 
kidney  slips  up  into  its  bed  when  the  patient  is  lying  on  her  back,  sometimes  inter- 
feres with  the  diagnosis,  for  palpation  then  would  show  no  displacement  of  the 
kidney.  In  order  to  prevent  a  prolapsed  kidney  from  being  pushed  into  place  un- 
awares, during  palpation  in  the  vicinity,  it  is  well  to  grasp  the  lumbar  region 
firmly,  as  shown  in  Fig.  413.  This  fixes  the  kidney  in  its  abnormal  position, 
where  it  can  be  palpated  by  the  fingers  of  the  other  hand,  as  shown  in  Fig.  414. 
Another  way  to  examine  a  movable  kidney  in  its  lowest  position,  is  to  palpate  the 
loin  while  the  patient  is  standing.  The  patient  must  lean  forward  on  some  support 
in  such  a  wav  as  to  relax  the  abdominal  muscles. 

17.  Tumor  of  Kidney.  Such  a  mass  may  be  traced  up  into  the  kidney  region. 
If  the  tumor  and  kidney  are  prolapsed,  they  maybe  returned  to  the  loin,  if  not  ad- 
herent. There  are  usually  dragging  pains  in  the  loin,  and  bladder  symptoms. 
Urinary  examination  may  give  decisive  information.  A  very  satisfactory  method 
of  palpating  the  kidney  region  for  a  mass,  or  for  deep  tenderness, is  to  use  both  hands, 
one  behind  and  the  other  in  front,  the  lumbar  structures  being  caught  between 
them  (Fig.  166). 

18.  Perinepheritic  Abscess,  without  cUstinct  fluctuation.  This  may  dissect 
down  into  the  lower  abdomen,  and  even  into  the  pelvis,  and  still  be  so  deeply 
situated  or  not  to  give  definite  fluctuation,  except  under  anesthesia.  The 
mass  may  be  traced  up  into  the  kidney  region.  There  is  colon  resonance  over  it. 
There  is  marked  tenderness  in  the  lumbar  region,  and  usually  decided  swelling  there. 
There  is  the  history  and  the  ordinary  signs  of  kidney  disturbance,  associated  with 
the  general  and  local  evidences  of  suppuration. 

19.  Psoas  Abscess,  without  distinct  fluctuation.  This  causes  a  deep  seated  mass 
in  the  lower  abdomen,  which  may  give  no  fluctuation  until  it  approaches  the  surface 
in  the  neighborhood  of  Poupart's  Ugament.  As  it  is  usually  tubercular,  the  marked 
local  tenderness  and  the  high  fever  and  chills  of  ordinary  deep  suppuration  are  gen- 
erally absent.  A  careful  examination,  however,  will  show  more  or  less  fixation  of 
the  thigh.  When  an  attempt  is  made  to  move  the  thigh  in  any  direction  that  pulls 
the  psoas  muscle,  the  movement  is  resisted.  There  are  also  other  evidences  of 
caries  of  the  lumbar  vertebrae. 

20.  Enlarged  Liver  or  Solid  Tumor  of  Liver.  The  liver  occasionally  becomes  so 
enlarged  from  disease  or  abscess  formation  that  its  lower  border  is  pushed  into  the 
right  lower  abdomen.  The  direct  connection  of  the  mass  with  the  usual  liver  dull- 
ness may  be  demonstrated,  and  the  lower  border  and  left  border  of  the  mass  has  the 
shape  of  the  liver  and  there  is  a  history  indicating  liver  disease.  A  tumor  from  the 
liver  usually  lies  in  front  of  the  intestines  and  its  connection  with  the  liver  may  be 
directly  shown  by  palpation  and  percussion.  Also,  there  is  a  history  of  liver  dis- 
turbance. 

21.  Movable  Liver.  Exceptionally  the  liver  may  be  so  movable  that  it  sinks  into 
the  lower  abdomen.  The  mass  lies  in  front  of  the  intestines,  has  the  shape  of  the 
Hver  and  may  be  returned  into  the  liver  region  unless  adherent. 


276 


GYNECOLOGIC  DIAGNOSIS 


22.  Tumor  of  Abdominal  Wall  (Fig.  124).  This  is  a  rare  condition,  and  for  that 
reason  it  is  Hkely  to  be  forgotten,  resulting  in  a  mistaken  diagnosis.  The  distin- 
guishing signs  of  a  tumor  of  the  abdominal  wall  are  given  in  the  first  part  of  this 
chapter  (page  121). 

23.  Inflammatory  Mass  in  Abdominal  Wall.  This  presents  about  the  same  signs 
as  a  tumor  of  the  wall,  with  evidences  of  inflammation  added. 

24.  Tumor  of  Round  Ligament.  It  arises  somewhere  in  the  course  of  the  round 
ligament, either  in  the  pelvic  cavity  or  in  the  inguinal  canal.  If  large,  it  necessarily 
produces  great  distortion  of  the  parts.  It  may  cause  much  confusion  in  diagnosis 
if  the  fact  be  not  remembered  that  a  tumor  occasionally  arises  from  this  ligament. 

25.  Some  Central  Abdominal  Mass.  One  of  the  firm  masses  mentioned  as  usually 
appearing  in  the  central  abdomen,  may  be  displaced  to  one  side  or  may  become  so 
large  that  it  extends  far  over  to  both  sides. 

26.  Mass  from  Opposite  Side.  Occasionally  an  enlarged  organ  or  a  tumor  from 
one  side,  will  become  so  much  displaced  as  to  appear  to  belong  to  the  other  side. 


^»34/^P£A/lf/X 


Fig.  415.     Double  Pyosalpinx  with  adhe.sions.     (Montgomery— Prncticnl  Gynecology  ) 


B.  Mass,  High  in  Right  Side,  Contains  Fluid. 

1.  Uterus  Displaced.     The  fluciuation  may  be  duo  to  pregnancy  or,  very  rarely, 
to  pyometra  or  to  homatometra. 


FLUCTUATING  MASSES  IN  IllGHT  SIDE 


277 


2.  Pyosalpinx  (Figs.  415,  416,  417).  There  is  a  tender  mass  in  the  tu])o-ovarian 
region,  ^vith  slight  or  well-marked  Ihictuation.  The  mass  is  fixed  and  the  uterus 
also  is  fixed.  There  may  be  a  large  amount  of  firm  exudate  or  very  little.  There 
is  usually  a  clear  history  of  infection  followed  by  the  usual  evidences  of  pelvic  in- 


Fig.  416.     Pyosalpinx  wiUi  uo  adliesions.     {KcWy— Operative  Gynecology . 

Hammation,  including  persistent  endometritis  with  discharge.  If  the  trouble  is 
gonorrhoeal,  the  symptoms  may  be  mild,  and  if  of  long  standing  the  pus-tube  may 
not  be  very  tender.  But  there  is  more  tenderness  and  more  thickening  and  fixation 
than  occurs  with  hydrosalpinx  or  ovarian  cyst  or  parovarian  cyst. 


Fig.  417.      Pyosalpinx  with  very  extensive  adhesions.     (Kelly — Opera- 
tive Gynecology.) 


3.  Ovarian  Abscess.  This  presents  practically  the  same  history  and  the  same 
signs  as  a  tubal  abscess.  In  fact,  it  is  sometimes  impossible  to  say  with  absolute 
certainty  whether  the  pus  is  in  an  enlarged  tube  or  an  enlarged  ovary.  As  the 
former  is  the  usual  condition,  we  assume  in  a  given  case,  that  the  pus  is  in  the  tube, 


278 


GYNECOLOGIC  DIAGNOSIS 


unless  there  is  something  special  pointing  otherwise.  Occasionally  in  an  abscess 
in  this  region,  the  form  can  be  made  out  as  distinctly  round  (probably  ovary)  or  dis- 
tinctly long  and  sausage-shaped  (tubal). 

4.  Tubal  Pregnancy.     This  presents  the  history  and  examination  signs  of  an  in- 
flammatory mass,  with  the  history  and  progress  of  tubal  pregnancy.     There  is,  in 


R.T. 


R.L. 


R.O. 


L.O. 


R.L. 


Fig.  418.  Right  Hydrosalphinx.  U.  Uterus  split  open.  R.T.  Right  Tube,  distended  with  fluid 
(hydrosalphinx) .  R.L.  Round  ligaments.  R.O.  Right  ovary.  (Keating  and  Coe — Clinical 
Gynecology .) 


the  class  of  cases  now  under  consideration,  sufficient  fluid  blood  encapsulated  some- 
where to  give  fluctuation,  either  about  the  tube  or  in  the  posterior  cul-de-sac. 

5.  Pelvic  Tuberculosis.  There  are  the  signs  of  a  chronic  inflammatorj^  mass,  "ndth 
a  collection  of  fluid  (tubercular  pus),  and  the  history  and  progress  of  the  case  pre- 
sent the  characteristics  of  local  tuberculosis,  as  explained  in  chapter  xi. 

6.  Hydrosalpinx  (Fig.  418).  About  the 
same  as  ovarian  cyst  except  that  it  is 
oblong  and  extends  from  the  uterus  to 
the  pelvic  wall  and  is  attached  along  the 
border  of  the  broad  ligament.  The  signs 
are  much  like  those  due  to  parovarian 
cyst, except  that  the  hydrosalpinx  is  situ- 
ated high  while  still  small.  There  nui}'  or 
may  not  be  a  history  of  pelvic  inflamma- 
tion at  any  time.  Its  intimate  attach- 
ment to  the  uterine  horn  is  an  impor- 
tant diagnostic  point. 
Fig.  419.    Ovarian  Cyst  of  Right  side,  dispiac-  7.  OvaHan  Or   Parovarian  Cyst.  (Figs. 

iiig  uterus  to  the  Left.'     (Montgomery— Prac«ca<  .,„      Ac-.rw        k.    n       i       ,-  ^      , 

Gynecology.)  '  419,420).    A  lluctuatmg  uiass,  somewliat 


FLUCTUATING  MASSES  IN  RIGHT  SIDE 


279 


movable,  of  slow  growth,  with  no  acute  symptoms  if  not  comphcatcd,  unless  caught 
in  the  pelvis,  and  there  is  considerable  abdominal  enlargement  before  xi^vy  trouble- 
some symptoms  appear.  The  mass  is  attached  in  the  pelvis  and,  by  further  ex- 
amination, its  attachment  may  l>e  traced  to  the  tubo-ovarian  region. 

8.  Cystic  Fibroid.  The  greater  portion  of  the  mass  is  usually  solid  and  presents 
the  characteristics  of  a  uterine  fibroid. 

9.  Large  Perityphlitic  Abscess.  Presents  the  history  of  appendicitis  with  per- 
sistent septic  symptoms,  and  the  evidences  of  a  pus  collection  in  the  vicinity  of  the 
caecum. 

10.  Cystic  Tumor  of  Kidney.  The  tumor  may  be  traced  up  toward  the  loin.  It 
is  freely  movable  usually,  unless  there  has  been  inflammation  about  it.    Good  flue- 


Fig.  420.     Graafian-FoUicle  Cysts  of  the  ovaries,  which  have  become 
intraligamentary.      (KeWy—Operativs  Gynecology.) 


tuation  is  not  obtained  through  a  moderately  thick  abdominal  wall,  unless  there  is 
some  large  cavity  or  a  number  of  small  ones  with  very  thin  walls.  The  tumor  may 
be  made  up  of  innumerable  small  cysts  and  yet,  in  the  ordinary  examination,  appear 
as  a  solid  tumor.  Under  anesthesia  the  fluctuation  may  usually  be  distinctly  made 
out.  Tenderness  is  slight  unless  there  is  complicating  inflammation.  The  en- 
larged kidney  is  usually  displaced  downward  considerably,  so  that  there  is  room  m 
the  loin  up  into  which  it  may  be  pushed.  The  colon  hes  over  the  mass,  between  it 
and  the  abnominal  wall.  This  may  not  be  apparent  at  first,  the  colon  being  flat- 
tened out  against  the  wall  and  causing  no  resonance  on  percussion.  The  fact  that 
the  colon  is  over  the  mass  is  easily  demonstrated  by  inflating  the  rectum  and 
colon  with  air.  This  was  necessary  in  the  case  of  the  tumor  shown  in  Fig.  204 
(see  also  Figs.  202  and  203). 


280  GYNECOLOGIC  DIAGNOSIS 

11.  Hydronephrosis  and  Hydro-ureter.  Occasionally  the  kidney  and  ureter  on 
one  side  will  become  very  much  dilated,  forming  a  sac  filled  with  fluid  (urine). 
There  is  usually  a  history  of  kidney  pains  and  bladder  disturbance  extending  over  a 
long  period  and  varying  much  at  different  times.  The  characteristic  feature  is  that 
the  sac  fills  at  times,  producing  a  swelling  with  more  or  less  tension  and  pain,  and 
then  after  a  variable  time  there  is  a  discharge  of  a  very  large  quantity  of  urine  with 
disappearance  of  the  swelling  and  relief  of  the  symptoms.  After  a  time  the  sac  fills 
again  and  discharges.  A  crucial  point  in  the  diagnosis  of  such  a  condition  is  the  coin- 
cidence of  the  disappearance  of  the  swelling  and  the  discharge  of  an  extraordinarily 
large  quantity  of  urine.  Too  much  dependence  should  not  be  placed  on  the  his- 
tory, as  it  is  more  or  less  uncertain  and  may  lead  to  an  erroneous  conclusion.  Be- 
fore the  patient  is  subjected  to  operation,  in  cases  where  the  symptoms  are  not 
urgent,  she  should  be  required  to  make  daily  measurements  of  the  amount  of  the 
urine  passed  during  one  of  the  periods  of  appearance  and  disappearance  of  the 
swelling,  in  order  that  any  marked  increase  in  the  amount  of  urine,  as  the  swelling 
disappears  or  diminishes,  may  be  known  positively. 

12.  Pyonephrosis.  When  the  dilated  kidney  or  ureter  becomes  filled  with  pus, 
there  is  marked  disturbance,  with  fever,  chills,  pains  extending  from  kidney  to  blad- 
der, usually  marked  bladder  disturbance  and  definite  urinary  findings.  Palpation 
of  the  kidney  and  along  the  course  of  the  ureter  gives  marked  tenderness.  An 
important  feature  in  these  cases  of  painful  kidney  trouble  is  the  point-tenderness 
on  deep  pressure  in  the  lumbar  just  over  the  kidney  (Fig.  164).  This  helps  to  dif- 
ferentiate kidney -tenderness  from  tenderness  due  to  appendiceal  or  other  intra- 
peritoneal inflammation,  which  differentiation  may  in  some  cases  be  practically  im- 
possible by  palpation  in  front.  Usually,  however,  careful  palpation  in  front  will 
show  clearly  that  the  tenderness  is  in  the  kidney  and  along  the  course  of  the  ureter. 

13.  Perinephritic  Abscess,  large  enough  to  give  fluctuation.  This  may  burrow 
into  the  pelvis  or  towards  Poupart's  ligament.  It  gives  deep  fluctuation  and 
presents  the  symptoms  and  signs  of  deep  suppuration  in  the  kidney  region. 

14.  Psoas  Abscess,  large  enough  to  give  fluctuation.  This  may  burrow  into  the 
pelvis,  or  beneath  Poupart  's  ligament  to  the  femoral  opening.  It  presents  fluctu- 
ation, both  superficial  and  deep,  and  gives  the  symptoms  and  signs  of  tuberculosis  of 
the  lumbar  vertebrae  with  involvment  of  the  psoas  muscle. 

15.  Dilated  Qall=bladder.  Occasionally  the  gall-bladder  becomes  so  greatly  en- 
larged and  displaced,  that  it  extends  into  the  lower  abdomen.  The  connection  of 
the  fluctuating  mass  with  the  liver  may  be  traced,  and  there  is  a  history  of  gall-stone 
disease  or  other  liver  disturbance. 

16.  Central  Abdominal  Affection.  One  of  the  cystic  masses  mentioned  as 
usually  appearing  principally  in  the  median  fine,  may  be  displaced  to  one  side  or 
may  become  so  large  that  it  extends  far  over  to  both  sides. 

17  Mass  from  Opposite  Side.  Occasionally  a  cystic  mass  from  one  side  will  be- 
come so  much  displeased  that  it  appears  to  belong  to  the  opposite  side.  Some 
months  ago  I  operated  on  such  a  case.  There  was  an  ovarian  cyst  extending  to  the 
umbilicus.  The  history  indicated  that  it  had  been  unusually  movable,  occupying 
various  positions  in  the  lower  abdomen.  When  I  saw  the  patient  she  had  been  sick 
in  bed  several  days  with  abdominal  pains  and  evidences  of  a  mild  peritonitis.    The 


MASSES  HIGH  IN  LEP'T  SIDE 


281 


large  fluctuating  mass  occupied  the  left  and  central  portions  of  the  lower  abdomen 
and  pelvis.  The  small  uterus  was  crowded  into  the  posterior  part  of  the  pelvis 
iiehind  the  cyst.  The  cystic  mass  was  not  very  tender,  hut  it  was  fixed  immovably 
by  adhesions.  From  its  location  there  seemed  no  room  for  doulH  that  it  arose  from 
the  left  side.  On  opening  the  abdomen,  however,  I  found  that  it  was  a  light 
ovarian  cyst  which  had  fallen  over  to  the  left  side  in  front  of  the  uterus.  The 
pedicle  had  become  twisted,  with  resulting  hemorrhage  into  the  cyst  and  fil^rinous 
peritonitis  about  it.  To  the  torsion  of  the  pedicle,  with  the  resulting  hemorrhage 
and  peritonitis,  were  due  the  acute  symptoms  and  the  recent  fixation  of  the  cyst. 

MASS  HIGH,  in  Pelvis  or  Lower  Al)(lomen,  LEFT   .Side. 
A.  Mass  or  Induration  FIRM. 

Same  as  on  right  side,  substituting  Sigmoid  flexure  for  Caecum,  and  Spleen  for 
Liver,  and  leaving  out  Appendicitis. 

B.  Mass  Contains  FLUID. 

Same  as  on  right  side,  substituting  Cyst  of  Spleen  for  dilated  Gall-Bladder,  and 
leaving  out  Perityphilitic  Abscess. 

MASS  HIGH  and  in  MEDIAN  LINE 

IX  PELVIS  OR  LOWER  ABDOMEN  OR  CENTRAL  ABDO.AIEN. 

A.  Mass  or  Induration  FIRM. 

Any  of  the  solid  masses  mentioned  as  occurring  in  the  Right  or  Left  side,  may 
extend  to  the  Median  line  or  across  it. 

There  are,  however,  certain  firm  masses  that  arise  in  or  near  the  median  line  and, 
consequently,  may  be  classed  as  belonging  to  this  median  region. 

1.  Solid  Tumor  of  Uterus.  Fibroid  tumors  are  the  most  frequent  cause  of  firm 
enlargement  of  the  uterus,  though  occasionally  a  malignant  tumor  of  the  corpus 
uteri  will  cause  marked  enlargement.  The  characteristics  of  these  have  already 
been  given.     There  may  exceptionally  be  both  carcinoma  and  fibroid  (Fig.  421). 

2.  Abdominal  Pregnancy  and  Lithopedion  (Figs.  422,  423,  424). 

3.  Solid  Tumors  of  Omentum,  Small  Intestine  or  Mesentery.  These  usually 
appear  near  the  median  line,  and  the  signs  vary  with  the  location.  The  diag- 
nosis rests  upon  the  presence  of  a  mass  presenting  the  symptoms  and  signs  to 
be  expected  in  a  tumor  from  one  of  these  structures,  and  for  which  no  more-common 
disease  would  account.  Such  tumors  usually  are  accompanied  by  gastro-intestinal 
symptoms. 

4.  Tumor  of  Pancreas.  A  deep-seated  mass  in  the  median  line,  accompanied  by 
decided  evidences  of  pancreatic  disturbance,  and  presenting  symptoms  and  signs 
for  which  nothin";  else  will  account. 


282  GYNECOLOGIC  DIAGNOSIS 

5.  Retroperitoneal  Tumor  (Fig.  201).  It  lies  back  of  the  intestines,  is  rather 
movable,  more  so  than  would  be  expected  from  a  pancreatic  tum.or,  and  is 
without  evidences  of  disturbance  of  any  particular  organ. 


Fig.  421.     Large  Ma-ss  in  PelvLs  formed  by  Uterine  Fibroids  and  Carcinoma.     (CuWen—Canca- of  the  Uterus.) 


6.  Enlarged  Lymphatic  Glands.     This  condition   presents  the  evidences   of    a 

retroperitoneal  or  mesenteric  mass,  accompanied  with  a  disease  causing  glandu- 
lar enlargement,  such  as  Hodgkin's  disease,  or  with  recent  ulceration  in  the  in- 
testine  (tubercular  or  typhoid). 


ADVANCED  EXl'RAUTERINE  PREGNANCY 


283 


7.  Tubercular  Peritonitis, 

without  c  !i  ()  u  g  h  fluitl  to 
given  fluctuation.  Tuber- 
cular inflammation,  with 
the  exudate  and  resulting 
mass,  may  occur  at  any 
part  of  the  peritoneal  cavity, 
but  is  likely  to  extend  into 
the  median  line,  if  not 
there  primarily.  The  pa- 
tient presents  the  evidences 
of  a  chronic  or  subacute 
peritonitis  with  nothing  else 
to  account  for  it,  and  the 
presence  of  tuberculosis  in 
the  intestines  or  in  the 
lungs. 

8.  Displaced     Abdominal 
Organ.     Several    cases    are 


Fig.   422.      Extrauterine    Pregnancy  near  full  term.     (Dudley- 
Practice  of  Gynecology.) 


Fig.  423.     Extrauterine    Pregnancy  with   Lithopedion,      Showing   the 
Lithopedion  in  situ.     (KsWy— Operative  Gynecology.) 


Fig.  424.  Showing  the  Lithopedion 
removed,  and  also  the  site  of  the  Tubal 
pregnancy.  {KeWy— Operative  GynecQlr 
ogy.) 


284 


GYNECOLOGIC  DIAGNOSIS 


recorded  in  which  a  displaced  organ,  such  as  the  kidney  (Fig.  425)  or  the  spleen, 
has  led  to  an  erroneous  diagnosis  and  an  erroneous  operation. 


Fig.  425.    The  Kidney  Displaced  into  the  Pelvis.     (Dudley— Prac- 
tice of  Gynecology.) 

B.   Mass,  High  and  in  Center,  Contains  Fluid. 

Any  of  the  fluid  masses  mentioned  as  occurring  in  the  Right  or  Left  side,  may 
extend  to  the  Median  line  or  beyond  it. 


Fig.  426.    A  Large  Cystic  Fibroid.     (Montgomery— Pwc/icff/  Gynecology.) 


FLUID  MASSEf?  IN  CENTRAL  I^OWER   ARDOMEN 


285 


There  are,  liowevor,  cei-laiiL  (hict  iKilini;- masses  lliaL  ai-is(!  in  (Ikj  nu^diaii  lino  and 
hence  may  be  said  to  belong  to   this  region. 

1.  Pregnant  Uterus.  This  may  be  any  size,  may  be  n(H'nial  or  abnormal,  and  the 
shape  of  the  uterus  maybe  regular  or  irregular. 

2.  Cystic  Fibroid  (Fig.  426).  It  presents  the  evidences  of  a  fil^roid  along 
with  fluctuation  in  a  part  of  it.  Where  such  a  condition  is  found,  be  careful  to 
exclude  pregnancy  complicating  the  fibroid. 


Fig.  427.    Ovarian  Cy.st  with  a  long  slender  pedicle.     (Montgomery— frac^ica?  Gynecology.) 


3.  Distended  Bladder  (Fig.  140).  This  may  cause  much  confusion  in  examina- 
tion and  diagnosis.  The  diagnostic  points  have  alread}^  been  given.  It  has  hap- 
pened that  the  unrecognized  distended  bladder  ruptured  with  fatal  results  (Fig. 
141). 

4.  Ovarian  or  Parovarian  Cyst  (Figs.  427,  428).  The  diagnostic  points  have  been 
given  briefly  in  this  chapter,  and  are  given  in  detail  in  chapter  xii. 

5.  Ascites.  For  the  differential  diagnosis  of  ascites,  see  text  and  illustrations 
under  Percussion  in  this  chapter  (page  157). 


286 


GYNECOLOGIC  DIAGNOSIS 


Fig.  428.     Dermoid  Cyst  filling  front  of  pelvis  and  displacing 
the  uteru?  Daclcward.     (Montgomery — Practical  Gynecology .) 


6.  Ascites  and  Tumor  (Fig. 
429).  The  important  percus- 
sion signs  of  ascites  and  tumor 
have  already  been  mentioned 
and  illustrated  in  this  chapter 
(see  Figs.  194,  195,  196.) 

7.  A  Cystic  Tumor  of  Omen= 
turn,  Intestine  or  Mesentery. 
A  considerable  number  of 
cystic  tumors  of  the  omentum 
and  mesentery  have  been  re- 
ported. Such  tumors  may 
cause  much  confusion  in  diag- 
nosis, unless  it  be  kept  in  mind 
that  they  may  be  encountered. 
The  symptoms  and  signs  they 
present  depend  on  the   situa- 


Fig.  429.  Ascites  and  Fibroid.  The  combination  closely  .simulated  pregnancy.  The 
abdomen  was  distended  with  a  Fluid  Mass  having  a  Solid  Mass  inside,  and  the  peculiarly 
shaped  fibroid  gave  ballot tement.     (Montgomery — Practical  Gynecology.) 


TABLE  ol'   l»TA(iN(»sriC   I'nINTS  ^f^J 

tion,  and  may  be  worked  out  for  the  different  situations  l-)y  a  consideration  of  the 
surrounding  structures  and  the  signs  that  would  Ukely  result.  The  diagnosis 
depends  largely  on  the  exclusion    of    the    more  common  conditions. 

8.  Pseudo-cyst  of  the  Lesser  Omental  Cavity.  This  is  usually  preceded  some 
months  by  an  abdominal  injury  involving  the  pancreas.  It  is  likely  to  be  of 
rather  slow  growth,  and  the  injury  may  be  overlooked  unless  the  history  is  carefully 
inquired  into.  In  all  cystic  masses  of  doubtful  character  near  the  center  of  the 
abdomen,  this  should  be  thought  of. 

9.  Cyst  of  Pancreas.  .  A  true  cyst  of  the  pancreas  may  present  nnich  the  same 
symptoms  and  signs  as  the  pseudo-cyst  of  the  lesser  omental  cavity  resulting  from 
an  injury  of  the  pancreas.  I  cannot  take  the  space  to  give  i-n  detail  the  differential 
diagnosis  of  these  various  upper  abdominal  conditions.  I  wish  simply  to  call  at- 
tention to  the  conditions  that  may  be  encountered,  and  the  presence  or  absence  of 
which  must  be  detern'.ined  by  the  examiner  through  further  .study. 

■10.  Cyst  of  Urachus.  This  and  other  rare  abnormalities  are  occasionally  met 
with.  A  cyst  of  the  urachus  is  found  in  or  near  the  median  line,  and  between  the 
peritoneum  and  the  anterior  abdominal  wall.  It  may  communicate  with  the  um- 
bilicus, causing  an  intermittent  discharge  there,  or  with  the  bladder  or  with  neither. 

POINTS  in  the  DIFFERENTIAL  DIAGNOSIS 

OF  VARIOUS  MASSES  IN  THE  PELVIS  OR  LOWER  ABDOMEN. 

The  majority  of  mistakes  in  diagnosis  are  due  not  so  much  to  want  of  knowledge 
as  to  lack  of  application  of  the  knowledge  possessed.  A  diagnosis  in  a  difficult  case 
implies  (first)  a  careful  examination,  by  which  are  obtained  the  essential  facts  of  the 
case,  and  (second)  correct  reasoning  and  a  logical  conclusion,  based  on  those  facts. 
A  mistake  in  diagnosis  may  be  due  to  failure  to  get  all  the  essential  facts — some  im- 
portant points  being  overlooked.  In  order  to  prevent  this  in  the  class  of  cases 
under  consideration  (presenting  a  mass  in  the  pelvis  or  lower  abdomen),  I  give  the 
following  table  of  points  to  be  considered.  In  a  difficult  case,  consult  this  table  and 
notice  whether  or  not  you  have  obtained  the  information  available  on  the  various 
points  mentioned. 

Examination  Findings.  ^^'  Consistency  of  Uterus. 

14.  Tenderness  of  uterus. 


15.  Mobihty  of  uterus. 

16.  Discharge  from  uterus. 

17.  Discoloration  of  cervix  or 


1.  Position  of  Mass. 

2.  Size. 

3.  Shape. 

4.  Consistency. 

5.  Tenderness.  ^^^S^^^-. 

6  Mobilitv  ^^'  I^slation  of  mass  to  tube  and 

7.  Attachments.  ovary. 

8.  Apparent  point  of  origin.  19-  Relation  of  mass  to  pelvic  wall. 

9.  Relation  to  uterus.  20.  Relation  of  mass  to  vaginal  wail. 

10.  Position  of  uterus.  21.  Bladder  (full,  distended,   uri- 

11.  Size  of  uterus.  nary  incontinence,  induration  in 

12.  Shape  of  uterus.  bladder,  pain  on  pressure) . 


288 


GYNECOLOGIC  DIAGNOSIS 


22.  Rectum  (containing  fecal  masses, 
or  indurated  or  painful  on  pres- 
sure) . 

23.  Mass  elsewhere  (arising  from 
uterus  or  about  tube  or  along 
colon.) 

24.  Colon  or  small  intestine  between 
mass  and  abdomen  wall. 

25.  Outline  of  dullness. 

26.  Shifting  (^f  outhne  of  dullness. 

27.  Hard  masses  within  a  cystic 
mass. 

28.  Pulsation  of  mass,  felt  on  exam- 
ination. 

29.  Fetal  movements,  felt  on  exam- 
ination. 

30.  Vascular  murmur  heard. 

31.  Fetal  heart-sounds  heard. 

32.  Fever  present. 

33.  Emaciation  or  fat  deposition. 

34.  Breast  disturbance  (tenderness, 
enlargement,  enlarged  veins  with 
milk  formation). 

35.  Evidence  of  disease  of  heart, 
lungs,  liver,  kidneys,  gastrointes- 
tinal tract,  spleen,  pancreas,  nerv- 
ous system. 

History  and  Subjective  Symptoms. 

36.  Manner  of  onset,  prominent  sym- 
toms  and  apparent  cause. 

37.  General  course  since. 

38.  Menstrual  disturbance. 

39.  Intermenstrual  bloody  discharge. 

40.  Leucorrhoea. 

41.  Pain  in  lower  abdomen  or  pelvis 
(pressure,  aching,  sharp  pain)  or 
about  external  genitals,  or  backache 
(sacral,  lumbar,  loin)  or  thigh  pains. 

42.  Fever. 

43.  Disability. 

44.  Variation  in-  weight. 

45.  Abdominal  enlargement. 

46.  Morning  sickness,  or  persistent 
nausea  or  vomiting  at  other  times. 


47.  Breast  disturbance — pains,  ten- 
tenderness,  enlargement,  pigmen- 
tation, enlarged  veins,  milk  forma- 
tion. 

48.  Bladder  or  rectal  disturbance, 
preceding  or  accompanying  the 
trouble. 

49.  Evidence   of    disease    of    the 
heart,  lungs,  liver,  kidneys,  gastro- 
intestinal tract,  spleen,  pancreas, 
nervous  system. 

Progress  Under  Observation. 

50.  Steady  increase  or  decrease,  or 
exacerbations,  etc. 

If  Examination  Under  Anesthesia 
Notice : 

51.  Exact  position  of  mass. 

52.  Exact  size  and  shape. 

53.  Consistency  throughout. 

54.  Exact  mobility. 

55.  All  the  attachments. 

56.  Point  of  origin. 

57.  Exact  relation  to  adjacent  organs, 

to  uterus, 

to  Fallopian  tubes, 

to  ovaries, 

to  rectum, 

to  colon. 

58.  Uterus — exact  position,  size, 
shape,  consistency,  (tenderness 
not  appreciable),  mobility,  attach- 
ments. 

59.  It  may  be  advantageous  to  make 
recto-abdominal  examination  also, 

60.  If  cervix  is  suspicious  of  malig- 
nant disease,  excise  a  piece  for 
microscopic  examination. 

If  Necessary  for  Diagnosis,  and 
Permissible  Under  the  Conditions 
Present,  Explore  the  Uterine  Cavity : 

61.  With  sound,  to  determine  depth 
and  direction. 


POINTS  IN  THE  SPECULUM  EXAMINATION 


28y 


62.  With  curet,  to  secure  tissue  for  area,  liard  nodule)  and  presence  of 
microscopic  examination.  retained  placental  remnants  or  pro- 

63.  With  finger,  to  determine  con-  jecting  polypoid  growths, 
sistency  of  uterine  wall  (softened 

POINTS  IN  THE  SPECULUM  EXAMINATION. 

In  the  speculum  examination,  direct  inspection  is  made  of  the  vaginal  wall  and 
the  cervix. 


Fig.  430.      Primary   Malignant   Ulceration  of   the  Vagina. 
{MontgoraeTy— Practical  Gynecology.) 


Conditions  of  Vaginal  Wall. 

The  vaginal  wall  may  present  arterial  congestion,  venous  congestion,  bleeding 
areas  or  distinct  ulceration. 

Arterial  Congestion  of  the  Vaginal  Wall  indicates  inflammation,  usually  acute,  or 
active  irritation,  as  by  an  irritating  discharge  or  pressary  or  other  foreign  body. 
The  differential  diagnosis  of  the  various  forms  of  vaginal  inflammation  has  already 
been  given  in  this  chapter,  when  considering  leucorrhoea  (see  page  177) .  Occasionally 
there  are  cases  of  chronic  vaginitis  in  which  there  is  arterial  congestion  in  spots.    In 


290 


GYNECOLOGIC  DIAGNOSIS 


such  chronic  cases  there  is  Ukely  to  be  infiltration  and  hypertrophy  of  the  con- 
gested areas,  giving  rise  to  tlie  condition  l^nown  as  granular  vaginitis. 

Venous  Congestion  of  the  Vaginal  Wall  should  always  arouse  a  suspicion  of  preg- 
nancy, for  that  is  the  most  common  cause.  It  may  be  caused,  also,  by  a  tumor  or 
other  pelvic  mass  that  interferes  with  the  vaginal  circulation,  or  by  extra-pelvic 
conditions  that  cause  venous  stasis  in  the  pelvis,  such  as  heart  disease  with  faihng 
compensation. 


£^^- 


Fig.  431.  Secondary  Malignant  Ulceration  of  the 
Vagina.  In  this  ease  there  was  a  carcinoma  of  the  en- 
dometrium, and  the  discharge  caused  an  implantation 
carcinoma  where  the  cervix  came  in  constant  contact 
with  the  posterior  vaginal  wall.  {KeWy— Operative 
Oynecology) . 


Bleeding  Areas  on  Vaginal  Wall,  without  a  distinct  ulcer,  are  found  principally 

in  senile  or  adhesive  vaginitis,  which  is  described  in  chapter  iv. 

A  Distinct  Ulcer  on  the  Vaginal  Wall  may  be  simple,  chancroidal,  syphiUtic, 
tubercular  or  malignant.  In  the  case  of  a  malignant  ulcer,  it  may  be  primary  on 
the  vaginal  wall  (Fig.  430)  or  it  may  be  secondary  (Fig.  431),  the  most  common 
source  of  secondary  malignant  ulceration  of  the  vaginal  wall  being  carcinoma  of  the 
cervix  uteri. 


ABNORMAT,  0(1NDITIONS  OF  THE  CERVIX 


291 


Conditions  of  Cervix   Uteri. 

The  appearance  of  the  normal  virgin  cervix  is  shown  in  Figs.  432  and  433.     The 

appearance  of  the  approximately  normal  cervix  in  the  parous  woman  is  shown  in 
Fig.  434,  and  a  cervix  that  has  undergone  the  senile  atrophy  is  shown  in  Fig.  435. 
Fig.  436  shows  discharge  from  an  unlacerated  cervix,  while  Fig.  437  shows  discharge 


Fig.  432.  Fig.  4.3.3. 

Fig.  432  and  433,  Varieties  of  Normal  Cervix  in  the  Virgin. 
Heitzmann — American  Text-book  of  Obstetrics.) 


Fig.  434. 
Fig.  434,  Cervix  of  Multipara.      (Norris,  after 


Fig.  435.     A  Senile  Cervix,  with  upper  part  of 
vagina.    (Edgar— Practice  of  Obstetrics.') 


Fig.  436.  Discharge  from 
seen  through  the  speculum. 
Gynecology.) 


the   Cervix     Uteri,    as 
(Massey — Conservative 


Fig.  437.  Discharge,  with  I.iiceiation  and  Erosion  of  the 
Cervix.     (Massey — Conservative  Gynecology). 


Fig.  438.  Erosion  of  the  CerriS,  witt  a 
few  scattered  cysts.  (H.  MacNaughton- 
J ones— Diseases  of  Women.) 


292 


GYNECOLOGIC  DIAGNOSIS 


(h-.-unjIai-  ci-osii.ji  <il' cfpvix:. 


i'\  sti'-   ill  GJf-iicrnl  ioi 
aft.-r  ];k:oi;U!0!\,. 


e<-p    slf'MaU'    Ificf-rat  ion 


T')  fsrcul  ii:      i.'K.crot  ion 
u-itli  erosion   f)f'oiielip 


Ml)  to  iruii.-i'  <>:. 


7ig.  439.    Lacerations  and  Erosions  of  the  Cervix.    (Mann— American  System  of  Gynecology.) 


LACERATION  OF  THE  CERVIX 


293 


Fig.  440.    Lacerations  and  Erosions  of  the  Cervix.     (Ma,nn— American  System  of  Gynecology.) 


294 


GYNECOLOGIC  DIAGNOSIS 


and  laceration.  Erosion  of  the  cervix  is  a  very  common  condition,  being  present 
to  a  greater  or  less  extent  in  most  cases  where  there  is  an  irritating  discharge. 
Fig.  438  shows  erosion  of  the  cervix,  the  shaded  area  extending  out  from  the  ex- 
ternal OS  representing  the  red  angry-looking  erosion.  A  few  small  glandular  cysts 
are  also  visible.  Various  appearances  of  lacerated  cervix,  as  seen  through  the 
speculum,  are  shoT\TL  in  Figs.  439,  440.  In  a  considerable  proportion  of  cases,  dis- 
tinct lips  are  noi  at  first  apparent,  the  lacerated  cervix  having  the  appearance  of  a 
ball  (Figs.  552,  441).  In  such  a  case,  if  the  anterior  and  posterior  portions  of  the 
cervix  be  caught  with  a  forceps  or  tenaculum  and  brought  together,  as  indicated 
in  Fig.  442,  the  extent  of  the  laceration  becomes  apparent. 


Fig.  441. 


Fig.  442. 


Figs.  441  and  442.  Testing  for  the  extent  of  the  tear,  in  cases  where  the  cervix  has  the  appearance  of  a  ball. 
The  center  of  the  anterior  lip  (A,  Fig.  441),  and  of  the  posterior  lip  (Bj  are  each  caught  with  a  tenaculum  and 
brought  together,  as  indicated  in  Fig.  442.     (B&\dy— American  Text-book  of  Gynecology.) 


Fig.  44.3.    Beginning  Epithelioma  of  the  Cervix.   (Samp- 
son— Johns  Hopkins  Hospital  Bulletin) 


Fig.  444.  Beginning  Carcinoma  of  the  In- 
terior of  the  Cer\-ix.  (Samp.^on— Jo/ni.5  Hopkins 
Hospital  Bulletin  ) 


IVlalignant  disease  of  the  cervix  causes  nianv  thousands  of  deaths  annually  and 
yet  in  the  beginning,  it  is  entirely  local  and,  when  recognized  early,  can  be  com- 
pletely removed.  The  diagnosis  is  considered  in  detail  in  chapter  ix.  Here  I 
wish  to  simply  call  attention  to  the  fact  that  beginning  malignant  disease  may  make 
very  little  change  in  the  general  appearance  of  the  cervix.  Any  suspicious  area 
should  be  carefully  investigated  and,  if  necessary  to  a  positive  diagnosis,  a  small 


MALIGNANT  DISEASE  OF  THE  CERVIX 


295 


piece  should  be  excised  for  microscopic  examination.     Beginning  malignant  disease 
of  the  cervix  is  shown  in  Figs.  443,  444,  445.     Fig.  446  shows  the  cervix  destroyed 


Fig.  445.  Epithelioma  of  the  C€r\'ix.  The  eerv'ix  has 
been  destroyed,  leaving  only  an  area  of  cancerous 
ulceration  at  the  top  of  the  vagina.  (KeWy—Operativo 
(rynecology.) 


296 


GYNECOLOGIC  DIAGNOSIS 


and  drawn  in  by  contracting  tissue,  so  that  no  ulceration  is  visible  through  the  spec- 
ulum.    But  in  the  vaginal  palpation  in  this  case  distinct  induration  was  felt  in  the 


Fig.  446.  Epithelioma  of  the  Cen-ix.  The  cer\-ix  has  been  de- 
stroyed and  the  affected  area  has  been  drawn  in,  by  the  gradual  con- 
traction of  the  infiltrated  tissues,  until  no  cancerous  tissue  can  be 
seen.  Palpation,  however,  shows  that  there  is  infiltration  of  the 
area  enclosed  within  the  dotted  line.  (_KeUy— Operative  Gynecology). 


area  bounded  by  the  dotted   line.     Fig.  447  shows  a  case  where  the  carcinoma  has 
appeared  in  the  form  of  a  papillary  growth. 


SIGNIFICANCE  OF  PAIX  I.\  LOWER  ABDOMEN 


297 


Fig.  447.  Epithelioma  of  the  Cerv-ix,  appearing 
as  a  Papillarj'  Growth.  (Kelly — Operative  Gynec- 
ology.) 


PAIN  IN  PELVIS  OR  LOWER  ABDOMEN. 

Pain  in  the  pelvis  or  lower  abdomen  may  be  due  to: — 

1.  Salpingitis,  acute  or  chronic.  Pain  referred  to  tubo-ovarian  region  (Fig.  148). 
History  of  preceding  uterine  inflammation,  with  cause  for  same.  If  chronic,  his- 
toiy  of  preceding  exacerbations.  On  abdominal  palpation,  tenderness  in  tubo- 
ovarian  region.  On  vaginal  and  bimanual  examination,  there  is  found  vaginal  dis- 
charge (evidence  of  preceding  uterine  inflammation)  and  marked  tendeness  in 
tubal  region.  Mass  is  indurated,  extending  up  to  uterine  horn  and  out  to  pelvic 
wall.  Fixation  of  upper  part  of  uterus  and  pain  on  movement  of  uterus.  Absence 
of  special  signs  of  tubal  pregnancy  or  of  chronic  oophoritis.  Mass  may  be  solid 
(consisting  only  of  exudate  or  infiltration)  or  may  give  more  or  less  fluctuation,  due 
to  serous  fluid  (hydrosalpinx)  or  to  pus  (pyosalpinx).  All  these  conditions  are  in- 
cluded under  the  term  salpingitis. 

2.  Oophoritis,  acute  or  chronic.  Acute  or  subacute  inflammation  of  the  ovary 
ordinarily  presents  practically  the  same  diagnostic  points  as  salpingitis,  is  usually 
associated  with,  and  over-shadowed  by,  the  salpingitis  and  is  included  under 
the  general  term  "pelvic  inflammation."  There  is  however,  one  rather  com- 
mon form  of  oophoritis  not  associated  with  salpingitis,  namely,  the  cystic  or  cir- 
vhotic    form.     When  not  associated  with  salpingitis  or  peritoneal  exudate,  there  is 


298  GYNECOLOGIC  DIAGNOSIS 

felt  on  bimanual  examination,  a  tender  mass  in  the  tubo-ovarian  region — rouaded, 
about  the  size  of  the  ovarj  or  larrger,  softened,  with  occasionally  a  fluctuating  area, 
movable,  often  lying  lower  than  ovary  usually  does  (prolapse  of  ovary  behind 
uterus)  and  when  pressed  upon  produces  a  peculiar  sickening  pain.  There  is  ab- 
sence of  peritoneal  exudate   and  there  is  no  fixation. 

3.  Pelvic  cellulitis.  Signs  same  as  in  salpingitis  except  induration  very  hard 
(unless  collection  of  pus)  and  occupying  connective  tissue  areas,  situated  lower  at 
side  of  uterus  and  intimately  connected  with  uterus  or  pelvic  wall. 

4.  Endometritis,  acute  or  chronic.  Pelvic  pain  shght,  sense  of  weight  and  pres- 
sure in  the  pelvis.  Uterine  discharge,  excessive  menstruation,  tenderness  of  uterus, 
no  induration  or  marked  tenderness  outside  uterus. 

5.  Backward  displacement  of  Uterus.  If  uncomplicated,  the  pelvic  pain  is  slight 
but  there  is  a  sense  of  pressure  and  weight.  Body  of  uterus  absent  in  front  of  cer- 
vix. Back  of  cervix  can  be  felt  a  mass  which,  on  further  investigation,  proves  to 
be  the  bodj^  of  the  uterus. 

6.  Fibroid  tumor  of  Uterus.  Unless  tumor  is  very  large  and  chokes  pelvis,  pel- 
vic pain  is  slight  but  there  is  a  sense  of  weight  and  pressure.  Frequently  uterine 
discharge  and  excessive  menstruation.  No  history  of  uterine  infection  or  attacks 
of  pelvic  inflammation.  Firm  mass  flrmly  attached  to  uterus,  not  tender,  not 
movable  separately  from  uterus,  but  uterus  and  mass  movable  together  in  pelvis 
(i.  e.,  no  fixation  of  uterus  and  mass  to  pelvic  wall)  except  when  tumor  is  so  large 
as  to  fill  pelvis.     In  deep  seated  fibroids,  mass  may  appear  as  an  enlarged  uterus. 

7.  Cancer  of  Uterus.  Leucorrhoea,  with  occasionally  a  streak  of  blood.  No  pain 
at  first  but  later,  when  uterus  is  much  enlarged  (cancer  of  corpus)  or  infiltration  in- 
volves parametrium  (cancer  of  cervix),  pain  appears.  If  in  the  cervix,  there  is 
indurated  area  or  an  ulcer  that  resists  treatment,  find  a  piece  should  be  excised  for 
microscopic  examination.  If  from  body  of  uterus,  there  is  a  leucorrhoeal  discharge 
or  a  blood-streaked  discharge  that  resists  treatment,  and  the  interior  of  the  uterus 
should  be  curetted  and  the  scrapings  examined  microscopically.  In  the  later  stages 
there  is  a  bleeding  mass,  yvith  indurated  margins,  d  site  of  cervix,  or  a  bloody 
watery  foul-smelUng  discharge  from  the  interior  of  the  uterus.  A  bloody 
foul-smelling  watery  discharge,  does  not  necessarily  mean  cancer.  It  may  be 
due  to  a  fibroid,  the  differential  diagnosis  being  made  by  microscopic  examina- 
tion of  clippings  or  curettings,  when  necessary. 

8.  Painful  Menstruation  (dysmenorrhoea).  Pain  due  to  menstruation  alone, 
occurs  only  at  the  menstrual  periods,  though  pain  from  most  any  pelvic  disease  may 
be  much  increased  at  the  menstrual  period, on  account  of  the  menstrual  congestion 
and  increased  nerve-sensitiveness.  The  various  causes  of  dysmenorrhoea  and  the 
differential  diagnosis,  are  given  in  chapter  xiv. 

9.  Pregnancy,  with  Threatened  Miscarriage.  Pains  are  usually  somewhat  parox- 
ysmal, missed  menses,  morning  sickness,  pains  in  breasts,  beginning  softening  of 
cervix,  uterine  body,  enlarged  and  softened,  elasticity  of  middle  segment  (Hegar's 
sign),  bluish  coloration  of  vaginal  walls  and  cervix. 

10.  Incomplete  Miscarriage.  History  of  early  pregnancy,  pain  and  passing 
of  blood  clots  or  "pieces  of  flesh,"  followed  by  a  bloody  discharge  and 
occasional  pains.     The  pains  are  usually  slight  (unless  infection  has  taken  place), 


SIGNIFICANCE  OF  PAIN  IN   LOWER  ABDOMEN  299 

the  principal  symptom  being  the  persistent  bloody  discharge.  Cervix  and  body  of 
uterus  softened.  Cervix  open,  and  sometimes  pieces  of  membrane  and  of  blood- 
clost  may  be  felt  projecting  out  of  it. 

11.  Tubal  Pregnancy.  Missed  menses,  morning  sickness,  uterus  slightly  en- 
larged and  softened,  tender  mass  in  tubal  region.  Diagnosis  on  these  signs  not  justi- 
fiable, unless  previous  examination  of  pelvis  has  shown  it  free  from  tubal  or  ovarian- 
inflammatory  trouble.  If  rupture  takes  place,  pain  and  tenderness  are  so  marked 
and  so  severe  at  first  as  to  preclude  satisfactory  palpation  of  tubo-ovarian  regions. 
If  hemorrhage  is  severe,  pulse  is  affected.  If  slight,  pain  disappears  and  mass  can  be 
made  out  beside  uterus  or  behind  it.  The  signs  at  this  stage  (slight  peritoneal 
hemorrhages  and  resulting  peritoneal  irritation  and  exudate)  are  the  same  as  for 
acute  salpingitis  w'th  exudate,  with  the  following  special  features: — 

a.  Bloody  vaginal,  discharge,  beginning  within  a  few  days  after  onset  of  pain 
and  continuing  in  an  irregular  way  from  one  to  several  weeks. 

b.  Only  slight  fever  or  none.  With  enough  acute  inflammation  to  cause  such 
severe  symptoms,  there  should  be  considerable  and  persistent  fever, 

c.  Evidence  of  internal  hemorrhage,  to  a  greater  or  less  extent. 

d.  Exaceibations  of  pain  -without  apparent  cause  and  without  decided  elevation 
of  temperatuie. 

e.  Absence  of  recent  intra-uterine  pregnancy  (miscarriage  and  infection  are  very 
common  causes  of  ordinar}^  salpingitis). 

12.  Pelvic  Tuberculosis.  P^vidences  of  pelvic  inflammation  (tenderness,  indura- 
tion or  mass  beside  or  behind  the  uterus  or  filling  pelvis,  fixation  of  uterus,  fever 
and  exacerbations),  with  the  special  features  given  for  pelvic  tuberculosis  in  chap- 
ter XI. 

13.  Tumor  of  Ovary,  Broad  Ligament  or  Fallopian  Tube.  A  mass  (usually  soft, 
fluctuating)  in  tubo-ovarian  region,  not  tender,  usually  freely  movable.  Not  in- 
timately attached  to  uterus,  no  fixation  of  uterus  unless  mass  is  large  enough  to  dis- 
place uterus  1o  side  of  pelvis.  Ovarian  growths  are  usually  freely  movable  and 
tend  to  rise  out  of  the  pelvis,  while  broad  ligament  growths  are  held  firmly  within 
the  brofd  ligament  and  cause  pain  and  uterine  displacement  while  still  small. 

14.  Laceration  of  the  Pelvic  Floor.  Loss  of  support  in  pelvic  floor  causes  more 
or  less  dragging  and  pressure  in  pelvis  (though  rarely  severe  pain),  present  princi- 
pally when  patient  is  on  her  feet, much  relieved  when  she  lies  down.  Feeling  of  weak- 
ness at  pelvic  outlet,  and  may  be  protrusion  of  parts  (colpocele,  cystocele,  rectocele, 
prolapse  of  uterus).     Examination  js'hows  marked  loss  of  support  in  pelvic  floor. 

15.  Acute  Vaginitis.  Pelvic  pain  slight  and  very  low  (more  of  pressure  and 
weight  and  burning),  free  discharge,  vulvar  and  urethral  irritation.  Examination 
shows  purulent  discharge  and  evidences  of  acute  inflammation  of  vagina. 

There  are  a  number  of  extra=genital  diseases  that  may  cause  pain  in  the  pelvis  and 
lower  abdomen  and  that  may  be  confounded  with  gynecological  affections,  and  that 
consequently  must  be  taken  into  consideration  in  differential  diagnosis.  Among 
them  may  be  mentioned  the  following: 

16.  Appendicitis.  Pain  more  diffused  through  abdomen  and  about  umbilicus 
at  beginning  of  attack.  Tenderness  at  McBurney's  point,  and  no  particular  tender- 
ness over  tube.     Mass  in  appendix  region,  and  not  in  tubo-ovarian  region.     Attacks 


300  GYNECOLOGIC  DIAGNOSIS 

associated  with  gastro-intestinal  symptoms  rather  than  with  uterine  symptoms, 
though  pain  may  be  \\orse  at  menstrual  periods  on  account  of  menstrual 
congestion.  Mass  may  involve  both  regions— if  in  virgin  probably  appendicitis,  if 
in  married  wTJman  probably  salpingitis. 

17.  Mucous  Colitis.  Causes  severe  attacks  of  pain  in  lower  abdomen  and  pelvis, 
and  has  frequently  been  mistaken  for  uterine  or  tubal  or  ovarian  disease.  Patients 
have  been  given  pelvic  treatment  for  months  and  years  and  have  even  had  the 
ovaries  removed  when  the  trouble  was  none  other  than  this  peculiar  affection  of 
the  colon.  The  affection  is  known  by  various  names,  such  as  membranous 
enteritis,  tubular  diarrhoea  and  mucous  colic. 

Osier  states:  "  It  is  a  remarkable  disease,  to  which  attention  has  been  paid  for  sev- 
eral centuries.  It  is  an  affection  of  the  large  bowel  characterized  by  the  production 
of  a  very  tenacious,  adherent  mucous,  which  may  be  passed  in  long  strings  or  as  a 
continuous  tubular  membrane.  I  have  twice  had  opportunity  of  seeing  the  mem- 
brane in  situ,  closely  adherent  to  the  mucosa  of  the  colon,  but  capable  of  separation 
without  any  lesion  of  the  surface.  According  to  W.  A.  Edwards,  80  per  cent,  of  the 
recorded  adult  cases  have  been  in  women.  The  cases  are  almost  invariably  seen  in 
nervous  or  hysterical  women  or  in  men  with  neurasthenia.  All  grades  of  the  affec- 
tion occur,  from  the  passage  of  a  slimy  mucous  like  frog-spawn  to  large  tubular  casts 
a  foot  or  more  in  length.  Microscopically  the  casts  are,  as  shown  by  Sir  Andrew 
Clark,  not  fibrinous  but  mucoid  and  even  the  firmest  consist  of  dense,  opaque,  trans- 
formed raucous.  It  is  due  to  a  derangement  of  the  mucous  glands  of  the  colon,  the 
nature  of  which  is  quite  unknown.  The  disease  persists  for  years,  varying  ex- 
tremely from  time  to  time,  and  is  characterized  by  paroxysms  of  pain  in  the  abdo- 
men, tenderness,  occasionally  tenesmus,  and  the  passage  of  flakes  or  long  strings  of 
mucous,  sometimes  of  definite  casts  of  the  bowel.  The  attacks  last  for  a  day  or  in 
some  cases  for  ten  days  or  two  weeeks.  Mental  emotions  or  worry  of  any  sort  seem 
particularly  apt  to  bring  on  an  attack.  Occasionally  errors  in  diet  or  dyspepsia 
precedes  an  outbreak.  Membrane  is  not  passed  with  every  paroxysm,  even  when 
pains  and  cramps  are  severe.  There  are  instances  in  which  the  morphia  habit  has 
been  contracted  on  account  of  the  pain.  There  may  be  marked  nervous  symptoms, 
and  authors  mention  hysterical  outbreaks,  hypochondriasis  and  melancholia.  The 
diagnosis  is  rarely  doubtful  (when  this  affection  is  in  mind)  but  it  is  important  not 
to  mistake  other  substances  for  membranes,  thus  the  external  cuticle  of  asparagus 
and  undigested  portions  of  meat  and  sausage  skins,  sometimes  assume  forms  not 
unlike  mucous  casts,  but  microscopical  examination  will  quickly  differentiate 
them." 

This  affection  may  prove  confusing  when  associated  with  endometritis  or  other 
pelvic  lesion.  The  points  in  the  differentiation  of  mucous  colitis  from  a  serious 
painful  pelvic  disease ,  are  the  character  of  the  pain  (resembling  intestinal  cramps 
and  extending  throughout  the  lower  abdomen),  the  passage  of  characteristic 
masses  of  mucous- in  some  of  the  attacks  and  the  absence  of  any  palpable  pelvic 
lesion  to  account  for  the  symptoms. 

18.  Other  Intestinal  Affections — digestive  disturbance,  enteritis,  colitis,  dysen- 
tery, typhoid  fever,  chronic  constipation  (with  distention  and  toxemia),  intestinal 
tuberculosis.     Each  of  these  may  cause  pain  in  the  lower  abdomen  and,  if   there 


SIGNIFICANCE  OF  PAIN  IN   LOWER  ABDOMEN  301 

happens  to  be  accompanying  uterine  symptoms,  may  lead  to  a  mistaken  diagnosis. 
Pain  is  more  widespread  and  variable.  Tenderness  on  palpation  is  more  general 
and  ill-defined,  all  the  lower  abdomen  being  more  or  less  tender  and  the  tenderness 
may  extend  above  the  umbilicus  and  into  the  flanks.  Uterine  and  tubo-ovarian 
region  not  especially  tender.  No  palpable  lesion  in  pelvis  to  account  for  symptoms. 
Special  gastro-intestinal  symptoms  elicited  on  questioning. 

19.  Peritoneal  Tuberculosis.  This  very  closely  resembles  ordinary  chronic  pel- 
vic inflammation  in  its  symptoms  and  course.  The  differential  diagnostic  points 
are  given  in  chapter  xi. 

20.  Kidney  or  Ureteral  Affections — movable  kidney,  nephrolithiasis,  pyone- 
phosis,  ureteritis,  and  tuberculosis  of  kidney  or  ureter.  Each  of  these  affections 
causes  attacks  of  pain,  involving  the  lower  abdomen  and  pelvis.  Pain  begins  in 
kidney  region  and  extends  downward  along  ureter  to  bladder.  There  may  or  may 
not  be  accompanying  bladder  disturbance  (frequent  or  painful  urination,  vesical 
tenesmus).  On  examination,  tenderness  in  kidney  region  is  elicited  by  accurate 
palpation  of  kidney  and  along  ureter,  and  there  may  be  displacement  or  enlarge- 
ment of  kidney.  On  bimanual  examination,  there  is  tenderness  in  bladder  or  along 
ureter  and  no  palpable  lesion  of  genital  organs  sufficient  to  account  for  symptoms. 
There  are  pathological  findings  in  the  urine. 

21.  Bladder  or  Urethral  Inflammation  or  Tumor.  History  of  bladder  symptoms 
(frequent  or  painful  urination,  vesical  tenesmus,  urinary  changes.)  On  examina- 
tion, tenderness  is  confined  to  urethra,  bladder  or  ureters,  there  are  pathological 
findings  in  urine  and  no  palpable  lesion  of  genital  organs  sufficient  to  account  for 
the  symptoms.  If  the  case  is  still  doubtful,  instrumental  examination  of  urethra, 
bladder  or  ureters  may  give  decisive  information. 

22.  Rectal  and  Anal  Diseases — proctitis,  hemorrhoids,  fissure,  new  growths. 
History  of  rectal  symptoms  (pain  on  defecation,  discharge  of  mucus  and  perhaps 
blood  at  times,  protrusion  of  hemorrhoidal  mass).  On  examination,  tenderness 
and  other  abnormalities  are  found  about  anus  and  extending  up  along  course  of 
rectum.     No  palpable  lesion  in  genital  organs  to  account  for  symptoms. 

23.  Nervous  Diseases — transverse  myelitis,  neurasthenia,,  hysteria,  pelvic  neu- 
ralgia. The  history  indicates  disturbance  of  the  nervous  system,  there  are  the 
special  features  of  one  of  these  nervous  affections  and  there  is  no  palpable  lesion  of 
genital  organs  sufficient  to  account  for  the  symptoms.  Pelvic  tenderness  is  con- 
fined to  the  pelvic  nerve  strands  or  to  the  otherwise  apparently  normal  ovaries. 
For  thorough  pelvic  examination  it  may  be  necessaiy,  in  order  to  overcome  mus- 
cular tension,  to  examine  under  anesthesia. 

24.  Coccygodynia  (painful  coccyx).  The  painful  affections  of  this  bone,  either 
following  injury  or  of  spontaneous  origin,  are  often  mistaken  for  some  genital  or 
rectal  affection.  The  pain  is  described  by  the  patient  as  at  the  very  end  of  spine, 
and  may  radiate  from  there  into  the  pelvis  or  down  the  thigh.  It  is  noticed 
especially  in  positions  that  occasion  movement  of  the  bone  (the  act  of  sitting  or  ris- 
ing, or  straining  at  stool,  or  walking  up  or  down  stairs)  or  that  cause  pressure  on 
the  bone  (resting  on  hard  surface,  riding  on  rough  road).  On  examination  with,  the 
finger  in  the  rectum  and  the  thumb  outside  on  the  bone  (Fig.  89),  there  is 
marked  tenderness  on  palpation  of  the  bone  and  pain  on  movement  of  same.    There 


302 


GYNECOLOGIC  DIAGNOSIS 


may  be  deformity,  indicating  previous  injury  or  inflammation.  The  marked  ten-  j 
derness  is  limited  to  the  region  of  the  coccyx.  There  is  no  palpable  lesion  of  the  i 
genital  organs  to  account  for  the  symptoms. 

BACKACHE. 

Backache,  either  in  the  lumbar  region  or  extending  down  over  the  sacrum,  may 
be  caused  by  most  any  of  the  conditions  mentioned  under  "pain  in  the  pelvis  and 
lower  abdomen. "     It  is  not  necessary  to  repeat  them  here. 

In  addition,  backache  may  be  caused  by  affections  of  the  muscles,  nerves,  Uga- 
ments  or  joints  of  this  region,  or  by  affections  of  the  bones  or  spinal  cord. 


REFLECTED  PAINS. 

Reflected  pains  do  not  occupy  as  large  a  place  in  gynecologic  symptomatology 
as  formerly.  We  have  come  to  look  upon  these  distant  pains  in  gynecological  cases 
as  usually  an  indication  of  some  intercurrent  or  complicating  trouble  at  the  site  of 

EndomelTilIS. 
■Bladder  » 


^-•Oiaphrapuji 


Ovary 


Fig.  448.     Showing  the  usual  cause  of  Reflex  Pains  in  tlie  various  regions.      (Dana —  Text-book  of 
Nervous  Diseases.) 


SIGNIFICANCE  OF  DISTURBANCES  OF  FUNCTION  303 

the  pain  o-r  of  an  abnormal  condition  of  the  nervous  system, rather  than  as  a  direct 
reflex  from  the  pelvic  trouble.  I  think  careful  investigation  will  show  this  to  be 
the  case  in  the  great  majority  of  instances  of  so-called  reflex  pains. 

In  rare  cases,  however,  the  connection  between  the  distant  pain  and  the  pelvic 
lesion  seems  very  close,  as  where,  for  example,  a  pain  in  the  head  or  other  situation  is 
made  to  disappear  by  correction  of  a  retrodisplacement  of  the  uterus,  only  to  re- 
appear as  soon  as  the  uterus  returns  to  its  malposition. 

When  reflected  pains  do  occur  they  are  likely  to  be  found  as  indicated  in  Fig.  448. 

DISTURBANCES  OF  FUNCTION. 

The  various  disturbances  of  function  (amenorrhoea,  menorrhagia,  irregular  men- 
struation, dymenorrhoea,  dyspareunia,  sterility)  constitute  important  symptoms 
of  disease  in  certain  cases.  They  are  considered  in  detail  in  chapter  xiv,  where 
the  various  causes,  and  consequePxtly  the  diagnostic  significance,  of  each  are  given. 


304 


CHAPTER    HI. 

GYNECOLOGIC  TREATMENT. 

In  Gynecologic   Treatment  the  following  therapeutic  measures  are  employed: 

Rest. 

Complete  Rest,  in  bed. 
Partial  Rest,  from  work. 
Sexual  Rest. 

Applications  to  Lower  Abdomen  and  Exterior  of  Pelvis. 

Moist  Heat. 

Hot  Stupes. 

Hot  Pastes. 

Hot  Poultices. 

Hot  Sitz-baths. 

Hot  Moist  Pelvic  Pack. 
Dry  Heat. 

Hot  Water  Bag. 

Japanese  Stove. 

Hot  Water  Coil. 

Electrotherm. 

Hot  Air  Chamber. 

Hot  Dry  Pack. 
Cold  Applications. 

Ice  Bag. 

Cold  Coil. 

Cold  Sitz-bath. 
Counter-Irritant  Applications. 

Mustard  (poultice,  plaster). 

Cantharides  (plaster,  collodion).. 

Tinct.  Iodine. 

Applications  to  External  Genitals,  Vagina  and  Cervix. 

Douches. 

Concentrated  Solutions. 

Powders. 

Tablets. 

Vaginal  Suppositories. 

Tampons. 

Tampon-capsules. 


LIST  OF  THERAPEUTIC  MEASURES  3C5 

Pessaries. 

Submucous  Injection  of   Substances. 

Local  Blood-letting. 

Curet. 

Cautery. 

Electricity. 

X-Ra3\ 

Finsen  Light. 

Radium. 

Intra-Uterine  Treatment. 

Medicated  Applications  within  uterus. 

Hot  Water  Irrigation. 

Curetment. 

Cauterization. 

Electricity. 

Cervical  Dilatation. 

Vacuum  Treatment. 

Applications  within  Rectum. 

Enemata,  Low  and  High. 
Hot  Water  Irrigation. 

Applications  to  Lower  Abdomen  and  Interior  of  Pelvis. 

Pelvic  Massage. 
Pressure  Treatment. 

Electricity. 

Applications  to  Body  Generally. 

Bathing. 

Friction  Rubbing  (with  alcohol,  salt,  brush,  etc.) 

General  Massage. 

Dress  Corrections. 

Postural  Methods  and  Exercise. 

Knee-Chest  Posture. 
Trendelenburg  Posture. 
General  Exercise. 
Special  Exercise. 

Internal  Treatment. 

Medicines. 

Diet. 

Psycho-therapy. 

Operations. 


50S  GYNECOLOGIC  TREATMENT 


REST. 


Complete  rest  in  bed  is  necessary  when  acute  inflammation  is  present  and  in  acute 

exacerbations  of  chronic  inflammation. 

In  an  acute  attack  of  vaginitis,  endometritis,  salpingitis  or  acute  pelvic  perito- 
nitis, tlie  patient  should  be  put  to  bed  and  kept  there  until  the  pain  and  fever  sub- 
side. When  the  inflammation  is  severe  and  accompanied  by  much  pain,  the  patient 
should  use  the  bed-pan  and  should  not  be  permitted  to  get  up  to  a  vessel  beside  the 
bed.  Also,  rest  in  bed  for  a  few  days  will  temporarily  diminish  the  pain  of  chronic 
inflammation  and  tlie  backache  and  distress  that  accompany  loss  of  support  in  the 
pelvic  floor. 

It  is  a  rule,  with  but  few  exceptions,  that  in  pelvic  disease  strict  rest  in  bed,  com- 
bined with  laxatives  and  hot  vaginal  douches  and  hot  applications  to  lower 
abdomen, will  in  twenty-four  to  forty-eight  hours  relieve  the  pain  to  such  an  extent 
that  the  patient  is  comfortable. 

The  exceptions  to  this  rule  are:— 

Active  spreading  inflammation  of  the  peritoneum, 

A  collection  of  pus  with  tension. 

Recurrent  hemorrhage,  as  in  tubal  pregnancy. 

Threatened  abortion. 

A  tumor  compressing  pelvic  nerves. 

Neuritis  and  neuralgia. 

In  these  conditions  the  pain  may  be  persistent  and  severe  in  spite  of  absolute 
rest.  By  keeping  these  things  in  mind,  the  effect  of  rest  becomes  a  help  in  differ- 
ential diagnosis  in  certain  cases. 

Partial  rest  is  advisable  in  many  cases  that  do  not  require  complete  rest  in  bed. 
The  work  of  some  patients,  requiring  as  it  does  much  walking  or  long  standing  or 
constant  running  of  the  sewing  machine  or  lifting  of  children,  tends  to  aggravate 
and  prolong  certain  pelvic  affections  and  for  that  reason  it  may  be  necessary  to 
have  the  patient  stop  work  for  a  while,  even  though  she  can  ill  afford  financially  to 
do  so.  Again,  it  may  be  advisable  to  direct  a  vacation  to  some  distant  point  for  the 
patient  who  is  dragged  down  by  household  duties  or  the  care  of  children  or  office 
work  or  the  exactions  of  society.  The  rest  from  care,  the  change  of  environment, 
the  direction  of  the  thoughts  and  activities  into  new  channels,  will  in  some  cases  do 
do  more  than  anything  else  toward  restoring  tlie  patient  to  health.  Directions 
should  of  course  be  given  for  whatever  additional  therapeutic  measures  are  neces- 
sary during  the  visit. 

Sexual  rest  is  necessary  in  many  cases,  particularly  in  inflammatory  troubles. 
In  some  cases  coitus  must  be  absolutely  forbidden  and  in  other  cases  restricted,  as 
the  marked  congestion  accompanying  it  is  likely  to  aggravate  the  trouble. 

In  acute  inflammation  it  is  rarely  necessary  to  say  anything  on  this  point,  as  the 
painfulness  of  coitus  itself  prevents  it.  In  sub-acute  inflammations  however  and 
in  chronic  conditions  aggravated  by  pelvic  congestion,  when  the  trouble  resists 
treatment  and  it  seems  probable  that  coitus  is  interfering  with  the  cure,  it  is  advis- 


APf'fJCATIONS  TO  TIIK  LOWER  AlJboMEN  307 

al^le  to  stop  .sexual  iiilcicoui'.sc  or  restrict  it.     Thi.s  may  be  acconipli.shcd  by  one  of 
three  ways,  as  follows: 

a.  Instructing  the  patient  or  her  husband  regarding  it.  This  is  .somewhat  em- 
barrassing and  not  very  effective,  though  it  is  sometimes  the  best  plan. 

b.  Use  of  vaginal  tampons,  the  tampons  to  be  worn  continuously  and  changed 
only  in  the  office.  In  this  way  the  beneficial  effect  of  tampons  is  .secured  and  at  the 
same  time  coitus  is  restricted.  The  tampon-capsules  when  indicated  for  other  pur- 
poses, may  be  used  so  as  to  accompUsh  this  object  also — the  patient  being  directed, 
on  removing  each  tampon,  to  take  a  douche  and  immediately  introduce  the  next 
one. 

c.  Sending  patient  on  a  trip  away  from  home.  Here  also  the  sexual  rest  is  only 
incidental,  though  quite  important  in  conditions  aggravated  by  pelvic  congestion. 


APPLICATIONS  TO  THE  LOWER  ABDOMEN  AND  EXTERIOR 

OF  PELVIS. 

These  applications  are  used  to  relieve  pain  and  limit  inflammation. 

MOIST  HEAT. 

Hot  stupes  are  made  by  folding  a  piece  of  flannel  several  times,  making  a  pad 
large  enough  to  cover  the  lower  abdomen.  This  pad  is  wrung  out  of  very  hot  water 
and  quickly  applied  to  the  abdomen  and  covered  with  a  piece  of  thin  oilcloth  or  a 
heavy  towel.  The  thin  oilcloth  is  preferable,  as  it  keeps  in  the  heat  and  moisture 
better  and  is  not  so  heavy.  As  soon  as  the  pad  begins  to  cool,  another  one  is 
wrung  from  the  hot  water  and  slipped  in  place  as  the  first  is  removed.  If  the  stupes 
are  changed  frequently  and  thus  kept  hot,  they  are  very  effective  in  relieving  pel- 
vic pain. 

They  have  some  effect  in  all  painful  conditions,  but  the  most  marked  effect  is 
seen  in  the  pain  of  inflammation.  The  efficiency  of  the  hot  stupes  may  be  increased 
by  adding  one  or  two  tablespoonfuls  of  turpentine  to  the  hot  water  in  the  basin. 
To  some  patients,  however,  the  odor  of  turpentine  is  disagreeable  and  disturbs  the 
stomach  and  with  such  it  should  not  be  used.  The  disadvantages  of  hot  stupes 
are  that  they  have  to  be  changed  very  frequently  and  that  they  soon  get  the  bed- 
clothing  damp. 

Hot  pastes.  There  is  a  material  for  external  use,  consisting  of  an  earthy  silicate 
for  a  base  and  having  incorporated  glycerine  and  mild  antiseptics  with  a  pleasant 
odor.  This  is  very  convenient  for  application  to  the  lower  abdomen  for  it  holds 
the  heat  and  moisture  well.  This  material,  with  slight  variations,  is  put  up  by  a 
number  of  firms  and  given  different  names  (glykaolin,  antiphlogistin,  etc.).  Under 
one  of  the  tradenames,  it  may  be  purchased  at  any  drug  store  in  one  or  two  pound 
cans.  The  methods  of  its  application  is  as  follows:  Take  oft'  the  lid  and  set  the  can 
in  a  pan  of  hot  water  on  the  stove  until  the  paste  is  thoroughly  heated.  It  is  then 
thin  enough  to  spread  easily  with  a  spatula  or  knife  or  spoon  handle.  It  is  spread 
directly  on   the  skin  in  a  thick  layer  (about  i  in.   thick).     The  whole  lower  abdo- 


308  GYNECOLOGIC  TREATMENT 

men  is  covered  with  a  thick  layer  of  the  hot  paste,  which  is  covered  with  a  piece  of 
flannel  and  outside  of  this  is  placed  the  hot-water  bag  or  Japanese  stove  to  keep  it 
warm.  The  paste  sticks  tight  to  the  skin  at  first,  but  after  twent5'"-four  hours 
usually  there  has  been  sufficient  perspiration  beneath  it  to  loosen  it  and  cause  it  to 
come  off  easily.  It  is  then  removed  and  a  fresh  layer  applied  immediately.  A 
fresh  application  is  made  every  twenty-four  hours,  as  long  as  hot  applications  are 
desired. 

Flaxseed  Poultice  retains  the  heat  well  and  is  much  used  as  a  home  remedy  when 
hot  applications  are  desired.  It  is  not  nearly  as  convenient  nor  cleanly  as  the  hot 
pastes  but  is  about  as  efficient  if  changed  often  and  kept  up  for  several  days,  and 
is  often  at  hand  when  the  other  things  are  not  available.  The  flaxseed  poultice  is 
made  as  follows:  Take  two  parts  of  ground  flaxseed  (flaxseed  meal)  and  five  parts 
of  boiling  water  and  mix  with  constant  stirring.  When  mixed,  spread  thick  (^ 
in.)  on  a  piece  of  thin  muslin  or  cheese-cloth.  Have  the  cloth  large  enough  so  that 
you  can  leave  a  margin  on  each  side  to  fold  over.  The  poultice  should  cover  one-half 
the  cloth  and  the  other  half  can  then  be  laid  over  after  the  margins  are  turned  in. 
If  a  hot-water  bag  or  Japanese  stove  is  at  hand  put  that  over  the  poultice  to  keep 
it  hot. 

Hot  Sitz-bath.  The  patient  sits  in  a  small  tub,  preferably  of  special  design,  con- 
taining watsr  enough  to  cover  the  hips,  genitals  and  lower  abdomen.  The  water 
should  be  as  hot  as  the  patient  can  stand  without  discomfort  (105°  to  115°).  She 
should  remain  in  the  sitz-bath  from  twenty  to  thirty  minutes  and  then  be  dried  and 
put  in  bed.  It  may  be  repeated  daily  or  several  times  daily,  as  found  most  bene- 
ficial. The  hot  sitz-bath  is  sedative  in  effect  and  relieves  very  much  the  pain  of 
pelvic  inflammation.  In  inflammation  it  should  be  used  only  in  those  cases  where 
the  patient  may  make  the  necessary  movements  without  detriment.  It  is  useful 
also  in  helping  the  onset  of  the  menses  in  amenorrhoea  or  suppi-essed  menses. 

Hot  Moist  Pelvic  Pack.  Instead  of  making  the  hot  applications  to  the  lower 
abdomen  only,  they  may  be  extended  all  around  the  pelvis.  The  whole  pelvis  is 
encased  in  the  hot  stupe  or  compress,  and  over  all  a  large  piece  of  thin  rubber  cloth 
or  table  oilcloth  is  placed.  A  woolen  blanket  also  is  wrapped  around  the  patient  to 
keep  in  the  heat  and  moisture.  This  may  give  much  relief  from  the  suffering  in  acute 
suppression  of  menses,  in  acute  pelvic  inflammation  and  in  severe  pelvic  neuralgia. 

DRY  HEAT. 

Hot=Water  Bag.  The  hot-water  bag  produces  almost  the  same  effect  as  the  hot 
stupes,  and  keeps  hot  a  longer  time  without  change  and  is  much  more  convenient 
to  manipulate.  If  the  effect  of  moist  heat  is  desired,  a  hot  stupe  may  be  applied 
and  a  hot- water  bag  placed  over  it  to  keep  it  warm.  If  no  hot-water  bag  is  at  hand, 
a  large  flat  bottle  filled  with  hot  water  may  be  used.  This  should  be  securely 
corked  and  wrapped  in  a  thick  flannel  cloth.  If  no  suitable  bottle  is  available,  a 
plate,  heated  and  wrapped  in  a  flannel  cloth,  may  be  used,  or  a  stove-lid  or  other 
article  that  will  retain  the  heat. 

Japanese  Stove.  This  consists  of  a  small  flat  metal  container,  about  the  size  of 
the  hand,  in  which  is  burned  a  compressed  powder  resembhng  charcoal.     This 


HOT  APPLICATIONS.     COLD  APPLICATIONS  309 

little  container  may  be  purchased  at  the  drug-store  for  a  few  cents  and  is  very  con- 
venient for  applying  dry  heat  or  for  keeping  a  moist  application  warm.  If  it  is 
wished  very  hot,  two  or  three  sticks,  instead  of  one,  of  the  powder  may  be  lighted 
and  dropped  in.     If  one  stove  is  not  large  enough,  two  or  three  may  be  used. 

Hot=Water  Coil.  This  consists  of  a  coil  of  rubber  tubing  and  a  boiler,  the  former 
being  attached  to  the  latter  by  tubing  in  such  a  way  as  to  cause  a  constant  circu- 
lation of  hot  water  through  the  coil.     It  is  very  nice  but  rather  expensive. 

Electrotherm.  This  electric  heating-pad  is  heated  by  a  current  through  a  cord, 
which  is  to  be  attached  in  the  ordinary  electric-light  socket.  This,  like  the  other 
dry  heat  appliances,  may  be  used  alone  for  dry  heat  or  over  a  moist  application  for 
moist  heat. 

Iiot=Air  Chamber.  The  apparatus  is  the  same  as  that  for  applying  hot  dry  heat 
to  the  joints  or  other  parts  of  the  body,  the  chamber  for  gynecological  cases  being 
made  to  fit  about  the  pelvis  and  lower  abdomen.  The  temperature  that  will  be 
borne  varies  with  individuals  and  also  with  the  length  of  time  employed.  At  first  a 
temperature  of  120°  for  twenty  minutes  will  suffice.  After  a  week  or  so  the  patient 
may  bear  a  temperature  of  135°  to  150°  for  45  minutes.  The  temperature  should 
not  be  high  enough  to  cause  discomfort  above  a  slight  tingling  of  the  skin.  The  air 
chamber  may  be  heated  with  electric  lights,  instead  of  in  the  ordinary  way.  This 
is  a  convenient  way  and  one  in  which  the  heat  is  easily  regulated. 

The  effect  of  the  hot  air  chamber  is  to  cause  marked  redness  of  the  skin,  free 
perspiration  and  a  hastening  of  the  absorption  of  chronic  pelvic  exudates.  Cases 
of  chronic  pelvic  inflammation  are  the  ones  suitable  for  treatment.  In  several 
cases,  exudates  were  absorbed  in  14  to  20  sittings.  No  bad  after  effects  were  noted. 
Cooling  is  allowed  to  take  place  gradually  and  the  patient  is  then  dried  and  lies  in 
bed  for  an  hour.  It  takes  considerable  time,  about  an  hour  to  each  patient,  but 
after  the  apparatus  is  once  started  it  may  be  left  in  the  care  of  an  experienced 
nurse. 

Without  any  special  treatment  about  90  per  cent,  or  more  of  pelvic  ex- 
udates tend  to  become  absorbed,  if  the  patient  is  kept  quiet.  This  natural  process 
is  hastened  by  laxatives,  hot  douches  and  heat  to  the  abdomen.  This  particular 
method  of  applying  heat  is  about  the  most  troublesome  and  expensive,  except  in 
hospitals  where  the  apparatus  is  kept  on  hand  or  in  homes  where  electricity  is  avail- 
able. In  cases  of  persistent  exudate  without  evidence  of  a  remaining  focus  of  in- 
fection, it  is  well  to  give  this  method  a  trial. 

Hot  Dry  Pack.  Dry  heat  may  be  applied  all  around  the  pelvis  by  packing 
around  it  hot  water  bags  or  hot  bottles  or  other  containers  for  maintaining  the 
heat,  the  skin  being  well  protected  by  layers  of  flannel. 

COLD  APPLICATIONS. 

In  some  cases  cold  gives  more  relief  than  heat,  though  the  cases  in  which  it  will 
do  so  cannot  be  certainly  determined  without  trial.  It  has  been  stated  that  cold 
gives  more  relief  when  the  pain  is  due  to  active  inflammation  and  the  hot  applica- 
tions in  other  cases.  In  my  experience,  that  rule  does  not  hold  good.  On  the 
other  hand,  in  the  majority  of  cases,    pelvic  pain,  inflammatory  or  otherwise;  is 


310  GYNECOLOGIC  TREATMENT 

relieved  more  by  hot  applications  than  by  cold.  Consequently  my  rule  is  to  use 
hot  applications  first  and,  if  they  fail  to  give  relief,  then  the  cold. 

There  are  several  ways  of  applying  cold.  To  get  the  best  sedative  effects  it 
must,  like  the  heat,  be  maintained  continuously,  or  almost  continuously,  for  sev- 
eral days. 

Ice  Bag.  The  ordinary  ice  bag  is  a  convenient  and  satisfactory  method  of  ap- 
plying cold.  If  no  regular  ice  bag  can  be  secured,  the  ice  may  be  put  in  a  hot- water 
bag.  The  ordinary  hot-water  bag  filled  with  ice  does  fairly  well  as  a  substitute  for 
an  ice  bag  but  it  is  not  as  convenient,  for  the  ice  has  to  be  broken  into-  very  sma41 
pieces.  If  no  rubber  bag  of  any  kind  is  at  hand,  the  broken  ice  may  be  wrapped 
in  a  towel  and  placed  in  a  piece  of  table  oilcloth,  the  edges  and  corners  being 
pinned  up  so  that  no  water  can  leak  out. 

CoId= Water  Coil.  One  end  of  the  coil  is  attached  to  a  vessel  of  ice  water  so  that 
the  water  runs  through  it  slowly  and  keeps  it  cold.  The  other  end  conducts  the 
water  from  the  coil  to  a  waste  bucket  beside  the  bed.  If  the  hydrant  water  is  cold 
enough,  the  tube  leading  to  the  coil  may  be  attached  to  the  hydrant. 

Cool  Sitz=bath.  This  is  used,  not  as  a  sedative  but  as  an  active  stimulant  to  the 
pelvic  organs.  It  is  taken  the  same  as  the  hot  sitz-baths  except  that  the  temper- 
ature of  the  water  is  70^  to  50°,  and  the  patient  does  not  stay  in  so  long — only  five 
to  twenty  minutes.  It  may  be  given  gradually,  i.  e.,  the  water  is  tepid  at  first  and 
gradually  cooled  to  60^  or  50°.  In  some  cases  in  which  amenorrhoea  is  due  to  local 
loss  of  tone  or  to  imperfect  development,  the  cool  sitz-baths  may  prove  more  bene- 
ficial than  the  hot.  They  should,  however,  be  given  cautiously  and  in  strong  in- 
dividuals only  and  should  not  be  continued  unless  good  reaction  comes  on.  As  in 
a  cool  general  bath,  the  reaction  should  be  encouraged  and  increased  by  prompt 
drying  and  brisk  rubbing. 

COUNTER-IRRITANT  APPLICATIONS. 

Mustard  Plaster.  A  mustard  plaster  or  mustard  poultice  is  applied  over  the  lowei 
abdomen  just  long  enough  to  produce  marked  redness  of  the  skin.  It  should  not 
be  left  on  long  enough  to  blister.  This  gives  a  quick  and  widespread  counter-irri- 
tation of  the  skin  and  assists  materially  in  relieving  acute  deep-seated  pain.  The 
effect  is  transitory  however,  and  needs  to  be  continued  by  the  ordinaiy  hot  appli- 
cations. If  there  is  smarting  of  the  skin  after  removal  of  the  mustard,  apply  a 
layer  of  vaseline  and  a  thin  cloth  under  the  hot  applications.  The  addition  of  tur- 
pentine to  plain  hot  stupes  is  a  form  of  counter-irritation,  and  in  some  cases  assist 
very  much  in  relieving  pain.  Of  course,  this  should  not  be  applied  to  the  abdomen 
in  a  case  where  an  abdominal  operation  may  be  necessary  soon. 

Cantharides  Plaster.  Small  fly  blisters  over  areas  of  persistent  pain  often  do 
much  good  in  cases  of  chronic  pelvic  inflammation  without  marked  lesion  and  in 
cases  of  pelvic  neuralgia.  The  blister  should  be  small,  from,  the  size  of  a  quarter 
to  that  of  a  dollar,  and  should  be  carefully  protected  from  infection  until  healed. 

Cantharides  Collodion  is  very  convenient  for  making  the  small  fly  blisters. 
Paint  it  over  the  area  which  it  is  desired  to  blister  and  repeat  after  twenty-fouj- 
hours  if  no  blister  has  appeared. 


VULVAR  AND  VAGINAL  TREATMENT  311 

Tincture  of  Iodine.  This  is  painted  over  the  ovarian  region  of  the  affected  side 
once  or  twice  daily  until  the  skin  becomes  tender.  Then  it  is  stopped  for  a  few 
days  until  the  skin-tenderness  subsides  somewhat,  when  it  is  renewed.  By  vary- 
ing the  application  as  indicated  by  its  effect  on  the  skin,  a  constant  mild  counter- 
irritation  may  be  kept  up  for  weeks,  often  with  decided  diminution  of  pain. 

APPLICATIONS  TO  EXTERNAL  GENITALS,  VAGINA  AND  CERVIX. 

VAGINAL  DOUCHES. 

The  vaginal  douche  is  used  for  four  purposes — for  simple  cleansing,  for  astrin- 
gent effect,  for  antiseptic  effect  and  for  the  specific  effect  of  hot  water. 

Cleansing  Douche.  The  simple  cleansing  douche  is  used  when  there  is  a  trouble- 
some increase  in  the  normal  muco-epithelial  discharge  or  when  there  is  a  muco- 
purulent discharge  wdthout  pain  or  evidence  of  inflammation  or  marked  relaxation 
of  the  tissues. 

Plain  boiled  water  comfortably  warm  (100^  to  105^)  may  be  used,  but  if  there  is 
much  discharge  it  is  well  to  put  a  teaspoonful  of  ordinary  salt  or  a  teaspoonful  of 
sodium  bicarbonate  to  each  pint  of  water,  or  the  carbolic  douche  may  be  pre- 
scribed (see  Formulae).  The  simple  cleansing  douche  may  be  taken  wdth  the  foun- 
tain syringe  or  with  the  bulb  (Davidson)  syringe.  It  may  be  taken  with  the  patient 
lying  in  bed  or  in  a  sitting  posture  over  a  vessel.  In  all  vaginal  douches  the  point 
of  the  syringe  nozzle  should  be  so  large  that  it  cannot  enter  the  cervical  canal. 
Serious  disturbance  and  even  death  has  followed  the  accidental  injection  of  the 
douche  solution  into  the  uterus.  The  point  of  the  nozzle  should  be  three-fourth 
inches  in  diameter,  wdth  the  end  closed  and  the  openings  at  the  sides.  When  it  is 
necessary  to  use  a  slender  nozzle  (as  in  giving  a  douche  to  a  virgin)  it  should  be 
very  short. 

Vaginal  douches  should  be  used  only  when  there  is  some  definite  indications  for 
them.  In  healthy  women  the  constant  use  of  douches  or  the  routine  use  of  them 
for  indefinite  periods,  is  not  advisable.  They  are  not  required  for  mere  cleanli- 
ness, in  fact,  they  interfere  in  a  measure  with  the  normal  germicidal  vaginal  con- 
tents, which  nature  has  provided  to  keep  the  vagina  in  a  healthy  condition  and  to 
protect  the  structures  above. 

Astringent  Douche.  The  astringent  douche  is  used  when  the  vaginal  walls  are 
lax  and  atonic  or  in  the  various  erosions  and  other  chronic  inflammatory  lesions  of 
the  cervix  and  in  cases  where  there  is  soft  bleeding  tissue  about  the  cervix  or  vagina. 

As  a  mild  astringent  and  sedative  douche  wdth  some  antiseptic  effect,  a  solution 
of  aluminum  acetate  is  exceptionally  efficient  (see  Formulae) .  Dissolve  the  powder 
in  boiling  water,  and  then  allow  it  to  cool  sufficienlly  for  the  douche.  It  is 
rather  difficult  to  dissolve,  that  from  some  manufacturers  more  so  than  from 
others.  The  aluminum  acetate  is  excellent  to  use  in  connection  with  the  hot 
douche,  the  last  two  quarts  of  the  hot  irrigating  douche  being  saturated  with  it 

When  a  stronger  astringent  effect  is  desired,  the  zinc  sulphate  and  alum  douche 
(see  Formulae)  or  the  tannic  acid  douche  (see  Formulae)  may  be  used.  These 
strong  astringent  douches  are  used  principally  in  cases  of  soft  bleeding  tissue  in  the 


312  ■    GYNECOLOGIC  TREATMENT 

vagina  or  in  cancer  of  cervix  or  vaginal  wall.     They  may  be  used  also  with  benefit 

in  relaxation  of  vaginal  tissues  and  in  erosions  and  other  chronic  inflammatory 
lesions  of  the  cervix,  in  cases  where  it  is  impracticable  to  use  the  hot  douche.  Care 
must  be  taken  that  the  solution  does  not  irritate  the  vaginal  wall.  It  is  well  to 
begin  with  a  weak  solution  and  advance  to  the  stronger  as  toleration  is  established. 

Astringent  douches  should  be  taken  with  the  patient  in  the  horizontal  posture, 
preferably  with  the  hips  elevated  on  the  bed-pan,  as  described  in  the  technique  of 
the  long  hot  douche  (Fig    449). 

Antiseptic  Douche.  The  antiseptic  douche  is  used  in  those  cases  of  purulent  dis- 
charge or  muco-purulent  discharge  in  which  the  admixture  of  pus  is  so  prominent 
that  an  active  germicidal  effect  is  important.  One  of  the  best  of  the  germicides 
for  making  a  strongly  antiseptic  douche  is  the  only  standby,  hydrarg.  bichloride, 
used  in  the  strength  of  about  1-5000  or,  where  a  weak  antiseptic  is  desired,  1-10,000. 
Some  state  that  it  is  dangerous  to  use  such  a  strong  antiseptic  as  a  vaginal  douche 
on  account  of  the  danger  of  poisoning.  This  is  hardly  probable  however  with  the 
strength  mentioned  and  under  precautions.  I  have  prescribed  it  freely  for  a  num- 
ber of  years  and  have  noticed  no  untoward  results.  I  am  careful  not  to  use  it  when 
there  is  a  large  raw  surface  in  the  vagina  or  when  there  is  an  opening  communicat- 
ing with  a  large  pelvic  abscess  cavity  or  when  the  cervical  canal  stands  open  so  that 
the  solution  might  easily  pass  into  the  uterus.  Absorption  from  the  intact  vagina 
is  not  probable.  In  prescribing,  it  is  well  to  have  the  concentrated  solution 
colored  (see  Formulae)  so  no  mistakes  will  arise,  for  it  is  a  violent  poison. 

Another  efficient  and  very  satisfactory  douche  is  formol,  1-5,000  to  1-3,000. 
Formol,  as  purchased  in  the  drug  stores,  is  a  40  per  cent,  solution  of  formaldehyde 
gas.  Formol  is  a  very  strong  antiseptic  and  must  be  used  in  weak  solution  or  it 
will  cause  irritation.  Five  to  ten  drops  to  two  quarts  of  warm  water  is  usually 
sufficient,  though  for  special  conditions  the  strength  may  be  increased  with  some 
patients. 

Hot  Vaginal  Douche.  The  hot  vaginal  douche  is  cleansing  and  may  be  made 
antiseptic  or  astringent,  but  its  special  and  distinct  effects  are  the  rehef  of  pain,  the 
limitation  of  inflammation,  the  hastening  of  absorption  of  exudates  and  the  toning 
up  of  relaxed  tissues.  These  effects  are  brought  about  by  the  prolonged  applica- 
tion of  hot  water  to  the  vaginal  walls  and  cervix. 

To  get  the  best  effect,  it  is  essential  that  particular  attention  be  given  to  certain 
details  of  its  administration.  These  details  are  usually  carried  out  in  an  incom- 
plete wa}^,  for  the  importance  of  their  full  employment  is  not  at  all  appreciated  by 
the  patient  and  as  a  rule  onh^  partially  by  the  physician.  Hence,  ordinarily,  the 
hot  douche  amounts  to  little  more  than  a  cleansing  douche,  the  specific  effect  of  the 
heat  being  almost  wholly  missed. 

This  is  an  important  subject  for,  given  properly,  the  hot  douche  is  one  of  the  most 
effective  non-operative  measures  used  in  the  treatment  of  gynecological  diseases. 
Furthei'more,  it  is  an  inexpensive  and  simple  measure,  the  necessary  articles  cost- 
ing but  little,  and  the  douche  may  be  given  to  the  patient  by  any  woman  of  ordi- 
nar}'-  intelligence,  if  definitely  instructed.  It  has  also  the  least  possibilities  of  harm 
of  the  various  methods  of  local  treatment  and  is  the  least  disturbing  to  the  anatomy 
and  physiology  of  the  parts.     The  specific  effect  of  the  hot  douche  was  recognized 


THE  HOT  VAGINAL  DOUCHE  313 

more  than  forty  years  ago  by  that  prince  of  cHnical  investigators,  Dr.  T.  A.  Emmet, 
and  clearly  set  forth  in  his  splendid  work  published  in  1879,  from  which  I  make  the 
following  quotation. 

"It  has  been  stated  that  the  sympathetic  system  of  nerves  presides  over  nutri- 
tion and  the  organs  of  generation  and  that  every  blood-vessel,  to  the  minutest  ca- 
pillary, is  covered  by  a  network  of  nerve  filaments  communicating  directly  with 
the  different  ganglia.  When  nutrition  is  impaired,  there  is  naturally  a  want  of 
tone  in  the  blood-vessels.  It  is  only  by  exciting  reflex  action  through  these  nerves 
that  the  necessary  tonicity  will  be  restored. 

"We  have  thi*ee  agents  for  exciting  this  reflex  action,  viz.,  electricity,  cold  and 
heat. 

"  Electricity  exerts  a  decided  effect  during  the  time  of  the  passage  of  the  cur- 
rent, but  the  impression  is  too  transitory  and  the  agent  is  only  to  be  relied  upon  as 
a  valuable  adjuvant. 

"Cold  is  a  prompt  excitor  of  reflex  action,  by  which  the  vessels  contract,  but  on 
reaction  taking  place  the  parts  will  become  more  congested  than  before,  with  both 
the  arteries  and  veins  distended. 

"  Heat,  unless  at  a  temperature  that  would  destroy  the  parts,  does  not  act  as 
promptly  in  causing  this  contraction  as  either  electricity  or  cold.  In  fact,  its 
immediate  effect  is  to  cause  relaxation  and  to  increase  the  congestion  of  the  parts, 
but  if  its  application  be  prolonged,  reaction  ensues  and  contraction  takes  place. 
In  other  words  the  reaction  from  heat  is  contraction.  The  capillaries  are  excited 
to  increased  action  and  as  they  contract  from  the  stimulus  of  these  nerves, the  tonic 
effect  extends  to  the  coats  of  the  larger  vessels,  their  calibre  in  turn  becomes  les- 
sened and  with  this  approach  to  healthy  action  the  congestion  is  diminished. 
The  popular  belief  is  that  heat  relaxes  and  increases  the  congestion  of  the  parts, 
and  such  indeed  is  the  cas'e  at  first.  But  a  hot  poultice  is  never  applied  with  the 
object  of  increasing  the 'congestion,  but,  as  any  'old  wife'  would  express  it,  to 
draw  the  'fire'  or  inflammation  out — in  other  words  it  lessens  the  congestion  by 
stimulating  the  blood-vessels  to  contract.  That  such  is  the  effect,  from  the  con- 
tinued use  of  a  poultice,  is  familiar  to  everyone  and  is  shown  by  the  blanched  and 
shriveled  appearance  of  the  tissues  after  its  removal.  The  hands  and  arms  of  a 
washer-woman  become  swollen  at  first,  from  the  increased  flow  of  blood  when  in 
hot  water,  but  the  fact  is  quite  as  familiar  that  they  afterwards  become  markedly 
shrivelled. 

"To  place  the  hands  in  cold  water  will  at  once  cause  the  skin  to  shrivel,  as  the  ves- 
sels are  stimulated  to  contract,  but  we  are  all  familiar  with  the  fact  that  reaction 
promptly  comes  on,  and  a  larger  quantity  of  blood  returns  to  the  parts  than  was 
driven  out.  The  immediate  effect  of  cold,  therefore,  is  contraction,  and  with  re 
action  comes  dilatation;  but  the  reverse  is  true  of  heat,  which  causes  at  first  dila- 
tation followed  however  by  contraction. 

"With  these  practical  points  before  us,we  resort  to  the  prolonged  use  of  hot  water, 
by  vaginal  injections,  to  gradually  bring  about  the  required  contraction  and  tone 
in  the  pelvic  vessels.  Whenever  inflammation  exists  we  have  congestion  of  the 
arterial   capillaries. ....... .The   congestion   may  be  either   venous   or   arterial. 


314  GYNECOLOGIC  TREATMENT 

This  remedy  Is  not  to  be  considered  a  '  cure  all, '  but  one  of  the  most  valuable 
adjuvants,  under  all  circumstances;  to  other  means. 

"If  a  vaginal  injection  has  been  properly  administered,  the  mucous  membrane 
Trill  be  found  blanched  in  appearance,  and  the  usual  size  of  the  canal  lessened  in 
calibre,  as  after  the  use  of  a  strong  astringent  injection.  As  the  patient  lies  on 
the  back  ^dth  her  hips  elevated,  the  action  of  gravity  will  be  brought  into  play,  by 
which  the  veins  will  be  rapidly  emptied  sufhciently  to  relieve  the  over-distension. 
When  in  this  position  also,  the  vagina  "^ill  become  fully  distended  by  the  weight 
of  water  and  kept  so,  since  only  the  surplus  amount  can  run  off  into  the  bed-pan 
beneath.  The  hot  water  T\'ill  then  be  in  contact  T^ith  everj'  portion  of  the  mucous 
membrane  under  which  the  capillaries  lie.  The  vessels  going  to  and  from  the  cer- 
vix and  body  of  the  uterus  pass  along  the  sulcus  on  each  side  of  the  vagina,  and 

their  branches  enclose  the  vagina  in  a  complete  network If  then  we  are 

able  to  cause  the  vessels  of  the  vagina  to  contract,  through  the  stimulus  of  the  hot 
water,  we  can  directly  or  indirectly  influence  a  large  part  of  the  pelvic  circulation. 
It  is  most  important  to  appreciate  the  necessity  for  elevating  the  hips,  by  which 
plan  so  large  a  portion  of  the  venous  blood  becomes  drawn  off  by  gravitation.  If 
the  stimulus  of  the  hot  water  is  then  applied,  so  as  to  cause  the  vessels  to  contract 
still  more,  we  will,  for  a  time  at  lea.st,  have  the  pelvic  circulation  reduced  almost  to 
a  natural  condition.  In  order  to  allow  the  condition  of  contraction  to  be  as  pro- 
longed as  possible,  I  generally  direct  the  injection  to  be  given  at  night,  in  bed,  just 
as  the  patient  is  ready  to  retire.  Thus,  by  constantly  causing  these  vessels  to  con- 
tract, and  by  resorting  to  every  other  means  of  lessening  the  supply  of  blood  in  the 
pelvis,  we  will  succeed  eventually  in  securing  a  proper  vascular  tone. 

''No  plan  of  treatment  could  be  more  rational  or  appeal  more  forcibly  to  the  good 
judgment  of  everyone.  But,  unfortunately,  from  a  neglect  of  details,  it  is  rare  that 
the  slightestbenefit  is  derived  from  these  injections,  although  so  many  years  have 
elapsed  since  the  profession  has.  been  fully  instructed  as  to  their  mode  of  action. 
For  fifteen  years  at  least,  I  have  been  experimenting  by  different  methods  in  the 
use  of  hot  water,  and  have  had  during  that  time  as  large  a  number  of  cases  as  would 
be  likely  to  be  at  the  service  of  anyone,  and  I  have  arrived  at  the  conclusion  that  it 
is  an  impossibility  for  a  patient  to  give  these  injections  to  herself  so  as  to  derive  their 
full  benefit.  Not  the  slightest  advantage  is  received  from  them  when  adminis- 
tered T^ith  the  patient  in  the  upright  position,  or,  as  is  the  usual  method,  while 
seated  over  a  bidet,  for,  given  thus,  the  water  does  not  dilate  the  passage  but  re- 
turns along  the  nozzle  of  the  syringe.  I  have  found  that  the  best  method  of  all  is 
to  have  the  injections  given  while  the  patient  is  placed  on  her  knees  and  elbows  or 
chest.  In  this  position  we  have  the  assistance  both  of  gravity  and  the  pressure  of 
the  atmosphere  to  empty  the  pelvic  veins,  while  the  water  is  able  to  act  on  a  much 
larger  surface  of  the  vagina  than  it  is  when  the  patient  is  in  any  other  position. 
But  this  position  is  a  difficult  one  to  assume,  since  those  who  are  in  the  greatest 
need  of  hot  water  have  not  the  strength  to  remain  in  it  long  enough  to  accomplish 
the  purpose,  and  considerable  difficulty  is  also  experienced  in  keeping  the  patient 
dry.  This  latter  difficulty,  how^ever,  can  in  a  measure  be  overcome  by  using  a 
funnel-shaped  receptacle,  with  an  india-rubber  tube  attached  to  the  smaller  end, 


THEORY  OF  THE  HOT  VAGINAL  DOUCHE  315 

the  two  sides  being  indented  sufficiently  to  enable  the  patient  to  keep  it  in  place  by 
keeping  the  thighs  together.  But  for  the  larger  number  of  cases,  the  position  on 
the  back,  with  a  bed-pan  to  elevate  the  hips,  will  be  found  the  most  convenient. 
Few  women  are  so  situated  as  to  be  unable  to  get  someone  to  administer  the  in- 
jection properly,  and  the  inconvenience  of  soliciting  aid  is  a  trifling  one  consider- 
ing the  benefit  to  be  derived  from  it,  since  experience  has  shown  that,  unless  the 
details  can  be  carried  out  fully,  the  process  only  involves  a  waste  of  time  and  a  tax 
on  the  strength  of  the  patient. 

"The  temperature  and  quantity  of  water  are  to  be  varied  according  to  circum- 
stances. When  treating  the  early  stages  of  inflammation,  it  is  necessary  that  the 
temperature  should  be  elevated  rapidly  from  that  of  blood  heat  to  110^,  or  to  as 
high  a  degree  as  can  be  borne  by  the  patient,  and  that  the  injection  should  be  often 
repeated.  For  ordinary  use,  a  gallon  of  water  at  two  or  three  degrees  above 
blood-heat  is  generally  sufficient,  but  the  temperature  must  be  maintained  at  the 
highest  point  by  the  addition  of  hot  water  from  time  to  time.  The  hour  of  bed- 
time is  usually  the  best  in  which  to  seek  for  the  beneficial  effects  of  hot  water  on 
the  reflex  system  in  allaying  the  local  irritation,  for  prolonged  vaginal  injection 
at  a  high  temperature  "v\ill  often,  when  gi^'en  by  an  experienced  hand,  act  with 
more  promptness  than  an  anodyne  in  allaying  the  nervousness  and  sleeplessness 
of  an  hysterical  woman.  I  have  frequently  known  a  patient,  after  being  well 
rubbed  and  having  received  an  injection,  to  fall  asleep  before  the  nurse  had  com- 
pleted the  process  and  to  be  so  overcome  with  drow^siness  as  to  be  but  little  dis- 
turbed on  removing  the  bed-pan. 

"In  rare  instances  and  from  a  condition  I  am  unable  to  explain,  cases  are  met 
with  where  a  sensation  of  weight  and  an  uncomfortable  feehng  are  experienced 
after  an  injection  of  water  at  the  usual  temperature.  In  some  instances  so  much 
disturbance  resulted  that  occasionally  I  was  obliged  to  abandon  its  use.  But  I 
have  long  since  ascertained  that  the  injection  is  well  borne  at  a  lower  temperature, 
generally  about  95^,  and  that  after  a  week  or  two  the  temperature  can  be  gradually 
increased. 

"This  '  cooking  process, '  as  it  has  been  facetiously  termed,  is  rendered  easier  by 
the  use  of  ivory  or  some  other  nonconducting  material  for  the  nozzle  of  the  syringe, 
since  the  patient  suffers  more  discomfort  from  the  heated  metal  surface  of  the  or- 
dinary nozzle  coming  in  contact  with  the  outlet  of  the  vagina  than  from  any  de- 
gree of  heat  in  the  water  which  it  is  advisable  to  employ. 

"To  the  injection  (generally  to  the  last  pint)  may  be  added  glycerine,  chlorate 
of  potash,  chloride  of  sodium,  carbonate  of  soda,  borax,  castile  soap,  sulphate  of 
copper,  muriate  of  ammonia,  brewer's  yeast,  permanganate  of  potassa,  carboHc 
acid  or  any  other  remedy  w^hich  may  seem  to  be  indicated. 

"As  the  patient  improves  in  health,  the  quantity  of  water  for  the  injection  may 
be  lessened  and  the  temperature  gradually  lowered  and  then  discontinued.  But 
for  some  months  it  would  be  prudent,  for  a  few  days  after  each  period,  to  resume 
the  injections  at  a  degree  or  two  above  blood  heat,  and  to  have  recourse  to  them 
whenever  their  use  should  seem  indicated  to  counteract  the  effect  of  some  impru- 
dence. 

"I  do  not  claimx  to  be  the  first  person  under  whose  direction  a  vagina  was  ever 


316 


GYNECOLOGIC  TREATMENT 


washed  out  with  warm  water,  but  I  do  claim  to  be  the  first  to  use  the  agent  in  a 
systematic  jnanner,  for  the  treatment  of  the  diseases  of  women,  and  to  have  done 
so  with  a  definite  purpose."* 

Directions  for  the   Hot  Vaginal  Douche. 

In  prescribing  the  hot  douche,  take  pains  to  give  exphcit  directions  on  the  fol- 
lowing points: — 


Fig.  449.  Patient  arranged  for  the  Long  Hot  Vaginal  Douche.  Notice  that  the  patient's  hips  are  elevated  and 
that  the  douche-pan  has  an  outlet  tube  leading  into  a  bucket  beside  the  bed.  The  douche-nozzle  has  a  thick  end 
and  the  openings  are  at  the  side,  so  that  there  is  no  possiblity  of  the  water  being  forced  into  the  uterine  cavity. 
The  douche-bag  may  be  hung  at  any  height  required  to  give  the  desired  rate  of  flow. 


1.  Articles  Required.    Direct  the  patient  to  buy  a  yard  of  thin  oilcloth,  a  douche- 
pan,  a  fountain  syringe,  a  bath-thermometer  and  a  four-ounce  bottle  of  lysol. 


Principles  and  Practice  of  Gynecology,  by  Thomas  ,\(klis  EmiucI,  M.  P. 


DIRECTIONS  FOR  THE  HOT  VAGINAL  DOUCHE  317 

The  patient  wishes  the  most  effective  treatment,  not  lialf-way  measm-cs.  These 
articles  cost  but  Uttle  and  are  necessary  to  the  proper  cure  of  the  case. 

The  piece  of  oilcloth  is  to  be  phiced  under  the  douche  pan  to  thoroughly  protect 
the  bed.  It  does  very  well.  A  piece  of  white  rubl)er  cloth  is  nicer  but  a  little 
more  expensive. 

A  very  convenient  form  of  douche=pan  is  that  shown  in  Fig.  449.  It  should  have 
an  opening  for  attachment  of  rubber  tubing  to  conduct  the  water  to  a  vessel  beside 
the  bed,  so  that  when  desired,  several  gallons  of  water  may  be  used  without  empty- 
ing the  douche-pan.  This  pan  holds  a  good  large  quantity  of  water  and  is  easily 
cleansed,  and  by  closing  the  outlet  with  the  screw,  cap  it  may  be  used  as  an  ordinary 
bed-pan.  A  douche-pan  of  this  or  some  similar  style  can  be  purchased  for  a  small 
amount  and  is  just  as  much  a  necessity  in  the  proper  treatment  of  the  case  as  med- 
icines that  cost  more. 

The  fountain  syringe  should  be  of  good  size  (3  or  4  qts.),  the  syringe-nozzle  hav- 
ing an  end  three-fourth  inches  in  diameter  and  with  the  openings  at  the  sides  (Fig. 
449).  The  nozzle  is  kept  in  2  per  cent,  lysol  solution  (two  teaspoonfuls  to  a  pint 
of  boiled  water)  when  not  in  use.  Immediately  after  use  each  time,  it  is  washed 
out  "^dth  a  stream  of  water  and  then  dropped  into  the  antiseptic  solution. 

The  bath=thermometer  should  register  as  high  as  120F.  It  is  kept  wrapped  in  a 
clean  towel.  Each  time  before  use  it  is  cleansed  in  the  lysol  solution.  After  use 
it  is  again  cleansed  in  the  lysol  solution,  dried  and  wrapped  in  towel. 

The  antiseptic  is  used  for  cleansing  the  douche-nozzle  and  the  thermometer, 
and  for  mixing  Tvith  the  last  two  quarts  of  the  douche  water  when  it  is  desirable  to 
do  so.  Any  antiseptic  desired  may  be  used.  Lysol  is  easily  obtained,  may  be 
mixed  in  approximately  the  required  proportions  very  easily,  does  not  corrode 
when  mixed  in  a  metal  vessel,  is  of  such  color  and  odor  that  it  is  not  likely  to  be 
mistaken  for  something  else  and  does  about  as  well  as  anything  so  far  as  antiseptic 
effect  is  concerned.  For  a  douche  use  ^  per  cent,  (one  teaspoonful  to  the 
quart).  If  an  astringent  effect  is  desired,  use  alum  (two  teaspoonfuls  to  the  last 
two  quarts)  or  aluminum  acetate  (one  teaspoonful  to  the  last  two  quarts) ,  instead 
of  the  lysol.  If  a  still  stronger  astringent  effect  is  desired,  the  zinc  sulphate  douche 
or  the  tannic  acid  douche  may  be  used.  The  formulae  for  these  various  douches 
are  given  in  the  Appendix. 

2.  Have  some  one  give  the  douche  as  follows: — Scald  out  the  douche-bag  and 
tubing  "v\ith  boiling  water  and  hang  it  about  three  feet  above  the  level  of  the  bed. 
Get  a  tea-kettle  of  boiling  water  and  a  large  pitcher  of  warm  water,  as  waim  as  the 
douche  may  be  comfortably  begun  with  (about  105°  by  the  bath-thermometer). 
Put  the  piece  of  thin  oilcloth  on  the  bed,  and  on  this  an  ironing  board.  Put  the 
douche-pan  on  the  lower  part  of  the  board  and  a  quilt  on  the  upper  part,  to  make 
it  comfortable  for  the  patient,  and  a  pillow  for  her  head.  If  the  upper  edge  of  the 
douche-pan  is  uncomfortable,  cover  it  with  a  folded  towel.  The  tube  of  the  douche- 
pan  leads  into  a  bucket  beside  the  bed. 

When  the  patient  is  arranged,  the  hips  should  be  considerably  higher  than  the 
rest  of  the  body  (Fig.  437).  Take  the  douche-nozzle  out  of  the  lysol  solution, 
rinse  off  the  lysol  in  the  pitcher  of  douche-water,  attach  the  nozzle  to  the  douche 
tubing  and  introduce  it  into  the  vagina.    Pour  some  of  the  warm  water  from  the 


3 IS  GYNECOLOGIC  TREATMENT 

pitcher  into  the  douche-bag  and  allow  it  to  run.  If  some  air  runs  from  the  douche- 
tube  into  the  vagina,  that  is  beneficial  for  it  helps  to  separate  the  walls.  As  the 
patient  can  take  the  water  warmer  and  warmer  increase  the  temperature,  bring- 
ing it  up  to  115^  if  not  too  uncomfortable. 

Keep  up  the  hot  irrigation,  ordinarily,  for  thirty  minutes  or  more,  using  as  much 
water  as  necessary  to  maintain  the  irrigation  for  that  length  of  time.  The  water 
runs  slowly  (only  two  or  three  feet  elevation)  and  three  or  four  gallons  is  usually 
enough. 

3.  If  it  is  desired  to  make  the  latter  part  of  the  douche  especially  astringent,  as 
when  the  parts  are  relaxed  and  atonic,  a  suitable  chemical  is  added.  The  alum- 
inum acetate  is  excellent  for  this  purpose,  a  teaspoonful  of  the  powder  being  dis- 
solved in  the  last  two  quarts  of  the  irrigating  fluid.  If  a  strong  antiseptic  effect  is 
needed,  as  in  a  case  of  purulent  discharge,  the  required  antiseptic  is  added  to  the 
last  two  quarts  of  the  hot  water. 

In  inflammation  (subacute  or  chronic)  considerable  additional  benefit  is  secured 
by  introducing  to  the  top  of  the  vagina,  immediately  after  the  douche,  a  vaginal 
capsule  containing  a  tampon  with  the  upper  end  saturated  Vvdth  some  glycerine 
preparation  (ichthyol-glycerine  or  boro-glycerine) .  This  tampon  is  left  in  place 
from  twelve  to  twenty-four  hours,  when  it  is  removed  and  the  douche  repeated. 
This  is  an  excellent  method  of  treating  subacute  or  chronic  pelvic  inflammation 
and  also  acute  exacerbations  of  the  same. 

4.  After  the  douche,  the  patient  slides  over  to  another  part  of  the  bed  while  the 
douche  pan,  etc.,  is  being  removed,  and  should  remain  quiet  for  at  least  an  hour. 

5.  The  frequency  with  which  the  douche  should  be  repeated  varies  with  the  case. 
In  chronic  inflammation,  when  the  patient  is  up  and  at  work  and  suffering  but 
little,  once  a  day  may  be  sufficient.  In  such  a  case  the  preferable  time  is  in  the 
evening,  as  the  patient  is  then  in  bed  for  several  hours  afterwards. 

In  cases  of  more  severity  or  where  the  one  douche  does  not  produce  satisfactory 
results,  a  douche  in  the  forenoon  may  be  added — the  patient  remaining  in  bed  at 
least  one  hour  afterward. 

In  the  cases  where  the  patient  is  confined  to  bed,  the  douche  is  given,  ordinarily 
twice  daily.  In  severe  cases  of  acute  pelvic  inflammation,  after  it  is  seen  that  the 
uterus  is  clean  and  draining  and  any  other  focus  of  infection  opened,  it  may  be 
beneficial  to  give  the  hot  douche  every  six  hours  and  in  some  exceptional  cases,  it 
is  advisable  to  keep  up  an  almost  constant  irrigation  of  the  parts  for  some  days. 

6.  This  hot  vaginal  douche,  with  its  specific  effect,  is  beneficial  in  practically 
all  inflammatory  conditions  of  the  pelvis,  in  relaxation  and  want  of  tone  in  the 
pelvic  tissues,  in  pelvic  congestion  and  in  pelvic  neuralgia.  In  these  conditions 
it  must  not  be  depended  on  to  the  exclusion  of  other  necessary  measures,  operative 
and  non-operative,  but  it  is  to  be  used  in  conjunction  with  these,  as  indicated  by 
the  requirements  of  the  particular  case. 

Where  many  gynecological  cases  are  treated,  it  is  well  to  have  a  printed  slip  to 
give  each  patient  who  is  to  take  the  douche,  setting  forth  definitely,  in  a  few  plain 
words,  the  necessary  directions.  By  having  this  to  refer  to,  the  person  who  gives 
the  douche  will  give  it  much  more  nearly  as  it  should  be  given  and  therefore-  much 
more  effectively. 


LOCAL  APPLICATIONS  319 


CONCENTRATED   SOLUTIONS. 

Before  taking  up  the  details  of  the  office  treatment  of  gynecological  diseases,  it 
would  be  well  to  get  a  clear  idea  of  what  good  can  be  done  and  what  harm  can  be 
done  by  such  treatment. 

The  importance  of  ordinary  office  treatment  is,  on  the  whole,  still  rated  much 
above  its  actual  value.  This  statement  applies  especially  to  the  application  of 
medicines  to  the  vaginal  walls,  to  he  cervix  and  to  the  interior  of  the  uterus.  In 
some  affections  for  which  this  method  of  t.eatment  is  generally  and  persistently 
employed,  it  does  no  good  and  much  harm. 

There  is,  however,  no  warrant  for  those  wholesale  condemnatory  statements 
made  from  time  to  time  which,  reduced  to  their  essence,  mean  that  when  any  pel- 
vic disturbance  is  severe  enough  to  require  treatment,  it  requires  operation.  Such 
teaching  is  very  far  from  the  truth  and  is  almost,  if  not  fully,  as  erroneous  in  theor}' 
and  deplorable  in  results  as  the  former  teaching  that  "local  treatment"  was  the 
most  important  measure  in  the  handling  of  patients  with  pelvic  disease.  Happily 
the  treatment  of  gynecological  diseases  is  no  longer  based  upon  obscure  theories 
and  opinions  empirically  expressed,  but  upon  the  rational  application  of  known 
remedies  to  demonstrated  pathological  conditions.  Though  there  is  still  much  to 
be  learned  and  much  that  is  obscure,  as  there  always  will  be  about  a  subject  so  inti- 
mately connected  with  the  mysterious  processes  of  life,  the  essential  features  of 
most  of  the  diseases  and  the  main  effects  of  the  principal  methods  of  treatment 
are  open  to  the  understanding  of  all  who  will  give  the  necessary  time  and  study  to 
the  subject. 

Critically  reviewing  the  demonstrated  pathological  changes  present  in  the  vari- 
ous gjmecological  affections,  it  is  evident  that  in  a  considerable  proportion  of  the 
serious  diseases,  effective  treatment  is  necessarily  operative,  for  the  abnormal 
changes  are  of  such  nature  that  they  can  be  influenced  only  by  direct  handling  and 
treatment  of  the  affected  organs.  On  the  other  hand,  there  are  many  conditions 
that  may  be  much  influenced  by  non-operative  measures  carried  out  at  home,  such 
as  attention  to  general  health,  internal  medicine,  special  exercises,  posture,  hot  or 
cold  external  applications,  hot  vaginal  douches,  etc.,  etc.  Much  effect  is  exer- 
cised also  over  certain  conditions,  by  local  treatment  in  the  office — pessaries,  tam- 
pons, packings,  pressure  treatment,  massage,  dilatation  and  various  medicinal 
applications  to  the  vagina  or  cervix  or  within  the  uterus. 

No  one  of  these  methods  should  be  used  until  sufficient  knowledge  has  been 
obtained  to  show  what  the  principal  effects  of  that  method  are  and  in  what  con- 
ditions we  may  reasonably  expect  decided  benefit  from  such  effects. 

The  method  just  now  under  consideration  is  the  application  of  concentrated 
solutions  to  the  cervix  uteri,  the  vaginal  wall  or  the  external  genitals. 
What  good  can  such  applications  do? 

1.  Tkey  may  exercise  an  antiseptic  or  an  astringent  or  an  anesthetic  or  an  irri- 
tating effect,  limited  to  the  surface  on  which  they  are  applied. 

2.  They  may  destroy  tissue  (cautery). 


320  GYNECOLOGIC  TREATMENT 

3.  They  may  draw  off  fluid  from  tissues  adjacent  to  the  vaginal  vault  (hygro- 
scopic effect),  as  in  the  use  of  glycerine  in  various  combinations.  This  may 
diminish  the  pain  (interstitial  pressure)  of  an  inflammatory  or  edematous  infil- 
tration and  possibly  assist  nature  in  limiting  the  inflammation  and  hastening 
absorption.  This  effect  is  very  desirable,  but  in  acute  and  subacute  cases  its  bene- 
ficial effect  is  more  than  overbalanced  by  the  trips  to  the  office.  In  such  cases  the 
effect  may  be  more  advantageously  secured  by  having  the  tampon-capsules  used 
at  home,  immediately  after  the  douche.  Occasionally,  in  the  case  of  a  chronic 
exudate,  when  the  patient  can  get  about  without  disturbance,  it  may  be  used  with 
decided  effect  in  office  work. 

4.  They  may  possibly  influence  deep  pains  by  counter-irritation  at  the  vaginal 
vault.  This  is  applicable  only  in  cases  of  chronic  exudate  or  pelvic  neuralgia, 
and  even  in  these  it  is  of  doubtful  utility.  Whether  the  decided  relief  of  pain  that 
sometim.es  follows  counter-irritation  at  the  vaginal  vault  is  due  to  the  mechanical 
drawing  of  the  blood  from  the  adjacent  tissues  to  the  dilated  vessels  of  the  vaginal 
surface,  or  to  a  reflex  deep  anemia  from  the  irritation  of  surface  nerve-filaments,  or 
to  a  purely  sensory  effect  on  the  deeper  nerves  by  irritation  of  the  corresponding 
superficial  nerves,  I  am  not  prepared  to  say.  Possibly  it  is  not  due  to  any  of  these 
but  to  some  other  factor  in  the  treatment  (pressure,  cleansing,  posture) . 

Formerly  much  importance  was  attached  to  counter-irritation  at  the  vagina] 
vault,  and  a  woman  with  pelvic  inflammation  could  hardly  be  considered  initiated 
into  treatment  until  the  vaginal  vault  and  cervix  had  been  painted  with  Churchill's 
tincture  of  iodine.  It  is  not  so  often  used  now,  for  we  have  more  effective 
measures. 

What  harm  can  such  applications  do? 

1.  May  cause  the  patient  to  come  to  the  ofl&ce  when  the  dressing  and  coming  do 
more  harm  than  the  application  does  good.  This  is  true  of  all  acute  inflammations 
(even  vaginal  and  vulvar)  and  of  practically  all  subacute,  inflammations  of  the 
uterus  and  deep  pelvic  structures. 

2.  May  cause  postponement  of  effective  treatment,  by  holding  out  false  hope, 
until  the  disease  is  much  more  difficult  of  cure  or  is  past  cure.  This  applies  to 
chronic  inflammations  of  the  corpus  uteri  and  peritoneal  structures,  to  deep-seated 
inflammatory  troubles  of  the  cervix  uteri  and  to  beginning  cancer  of  the  uterus. 

3.  May  convert  a  neurasthenic  or  hysteric  into  a  confirmed  invalid  by  fixing  at. 
tention  upon,  and  exaggerating  the  importance  of,  some  trivial  local  disturbance. 
In  such  patients  the  frequent  calling  of  the  attention  to  some  minor  disturbance 
in  any  part  of  the  body  is  deleterious  and  particularly  so  if  the  disturbance  is  in 
the  genital  tract,  for  the  importance  of  minor  disturbances  there  is  greatly  over- 
rated in  the  minds  of  people  generally.  For  this  reason,  in  patients  with  neuras- 
thenic or  hysteric  tendency,  I  rnake  it  a  point  to  avoid  repeated  local  treatments, 
even  in  some  conditions  where  otherwise  I  would  feel  that  they  might  be  beneficial. 
Occasionally  local  treatment  of  an  unimportant  lesion  two  or  three  times,  princi- 
pally for  psychic  effect  and  to  gain  the  patient's  confidence  by  letting  her  see  that 
you  appreciate  all  that  is  there,  is  beneficial.  Usually,  however,  the  same  effect 
is  better  accomplished  by  a  thorough  examination  and  then  an  unequivocal  dis- 
missal of  those  organs  from  the  list  of  damaged  structures. 


VARIOUS  SOLUTIONS  USED  321 

The  concentrated  solutions  used  for  application  to  the  vaginal  walls  or  cervix, 
are  applied  through  a  speculum  by  means  of  a  pledget  of  cotton  held  with  a  uterine 
dressing  forceps,  or  by  means  of  a  cotton- wrapped  applicator.  These  solutions  may 
be  divided  into  several  groups,  according  to  effects.  I  do  not  give  all  the  solutions 
under  each  group  but  only  some  well  known  examples. 

Solutions  Used. 

!.  Antiseptic  and  astringent  solutions. 

Protargol  Sol.  2%  to  10%. 
Argja-ol  Sol.  20%  to  40%. 
Silver  Nitrate  Sol.  2%  to  10%. 
Bichloride  Sol.  1  to  500. 
Tinct.  Iodine. 
Copper  Sulphate  Sol.  10%. 
Adrenalin  Chloride  Sol.  1-1000. 
Liq.  Ferri  Subsulphatis. 

Silver  Nitrate  solution  is  the  one  former .y  most  commonly  used  as  an  antiseptic 
apphcation  to  the  genital  tract.  It  is  still  used  largely  and  with  excellent  effect, 
though  there  are  some  other  preparations  with  the  same  effect  and  mthout  the 
pain  on  apphcation  and  the  discoloration  of  the  clothing  incident  to  the  use  of 
silver  nitrate.  Silver  nitrate  is  the  pioneer  of  the  silver  preparations.  It  is  used 
in  the  treatment  of  vulvitis,  vaginitis,  erosion  and  ulcer  about  cervix,  endocervicitis 
and  endometritis.  The  strength  used  for  vulva  and  vagina  is  usually  2  per  cent, 
to  4  per  cent.,  the  weaker  being  used  at  first  when  the  parts  are  particularly  sen- 
sitive and  the  stronger  later  as  the  sensitiveness  becomes  less.  A  sensitive  in- 
flamed surface  or  an  abrasion  or  ulcer  is  usually  much  diminished  in  sensitiveness 
after  one  or  two  appUcations,  and  the  application  seems  also  to  stimulate  repair. 
For  application  to  an  eroded  area  or  an  ulcer  on  the  cervix,  4  per  cent,  to  10  per 
cent,  is  used  to  stimulate  repair. 

During  the  last  few  years  a  number  of  silver  preparations  have  been  put  forward 
as  superior  to  silver  nitrate  for  local  application.  Protargol  and  Arg}^rol  are  two 
that  have  stood  the  test  of  extensive  use.  They  have  about  the  same  or  perhaps 
a  better  effect  than  silver  nitrate,  do  not  irritate  so  much  and  do  not  form  perma- 
nent stains  on  the  clothing  and  skin.  The  protargol  is  used  in  the  same  strength 
as  silver  nitrate.  The  argyrol  must  be  used  much  stronger,  20  per  cent,  to  40  per 
cent.     It  is  the  least  irritating  of  the  silver  preparations. 

The  bichloride  solution  is  strongly  antiseptic  and  mildly  astringent. 

Tincture  of  iodine  (either  the  ordinary  tincture  or  Churchill's  tincture)  is  a  use- 
ful antiseptic  and  stimulant  to  chronically  inflamed  areas  or  to  erosions  or  ulcers. 
It  was  formerly  much  used  as  a  counter-irritant  application  to  the  vaginal  vault  in 
chronic  pelvic  inflammation,  but  more  effective  measures  for  the  treatment  of  this 
disease  are  now  available. 

The  copper  sulphate  solution  is  used  to  check  bleeding  and  to  stimulate  healthy 


322  GYNECOLOGIC  TREATMENT 

cell  action  in  eroded  and  ulcerated  areas.  It  has  a  tendency  to  check  bleeding 
from  all  ulcers  except  those  due  to  beginning  malignant  disease.  Consequently  it  is 
helpful  in  the  differential  diagnosis  of  a  maUgnant  ulcer,  as  explained  in  chapter  ix. 

Liq.  Ferri  Subsulphatis  maj^  be  used  when  a  strong  hemostatic  application  is 
needed  for  a  bleeding  area. 

Adrenalin  affects  different  parts  of  the  mucosa  of  the  genital  tract  in  a  different 
manner.  It  seems,  in  some  cases  at  least,  to  have  no  effect  on  the  mucosa  of  the 
vagina,  but  a  pronounced  effect  on  that  of  the  uterus. 

2.  Cauterizing  Solutions. 

Carbolic  Acid  95%. 
Iodized  Phenol. 
Nitric  Acid— C.  P. 

Carbolic  acid  is  employed  as  a  cauterant  application  to  unhealthy  ulcers  on  thft 
cervix  or  vaginal  wall,  particularly  chancroidal  ulcers. 

lodized-phenol  (see  Formulae)  is  a  milder  cauterant,  more  superficial  and  less 
irritating  than  carbolic  acid  and  also  less  effective.  Nitric  acid  is  a  very  deep  and 
painful  cauterant.  It  is  now  seldom  used,  as  carboUc  acid  is  effective  and  is  easier 
handled  and  causes  less  subsequent  disturbance, 

3.  Hygroscopic  Solutions. 

Glycerine. 

Boro-glycerine  (Boric  acid  50%). 
Carbol-glycerine  (Carbohc  acid  2%). 
Ichthyol-glycerine  (Ichthyol  10%). 
Protargol-glycerine  (Protargol  10%). 
Tannic-acid-glycerine  (Tannic  acid  10%). 

The  glycerine  preparations  are  used  for  the  hygroscopic  (water-extracting)  effecf 
of  the  glycerine  and  also  for  the  special  effect  of  the  particular  drug  incorporated 
with  the  glycerine.  The  application  is  made  by  soaking  one  end  of  a  tampon  in 
the  desired  glycerine  preparation  and  then  introducing  it  through  the  speculum 
into  the  upper  part  of  the  vagina,  the  medicated  end  being  placed  against  the  cer- 
vix. These  glycerine  tampons  are  used  particularly  in  acute  and  chronic  inflam- 
matory conditions  in  the  pelvis.  They  seem  to  assist  materially  in  diminishing 
the  pain  and  soreness  and  they  certainly  exercise  a  decided  effect  on  the  adjacent 
tis.sue  fluids,  for  the  patients  often  remark  on  the  large  amount  of  water  which 
comes  from  the  vagina  when  using  these  glycerine  tampons. 

4.  Anesthetic  Solutions. 

Cocaine  Sol.  10%. 

Cocaine  Sol.  i%  (for  hypodermic  injection). 

Eucaine  Sol. 

Chloretone  Sol. 


VARIOUS  POWDERS  USED  323 

The  10  per  cent,  cocaine  solution  is  used  for  local  application  to  painful  sores  or 
abrasions,  to  diminish  pain  during  examination  or  cauterization. 

The  y  per  cent,  cocaine  solution  is  used  as  a  subcutaneous  or  submucous  in- 
jection, for  removing  small  growths  or  pieces  of  tissue  for  microscopic  examination. 

POWDERS. 

Powders  may  be  applied  by  means  of  the  powder  blower  or  they  may  be  placed 
on  a  cotton  or  gauze  tampon,  which  is  then  placed  in  the  upper  part  of  the  vagina 
Powders  innumerable  have  been  used  for  this  purpose,  and  as  a  rule  any  powder 
that  is  a  good  antiseptic  application  for  wounds  is  good  also  as  a  vaginal  applica- 
tion. 

Powders  are  used  principally  for  the  antiseptic  and  drying  effect  or  for  an  anes- 
thetic effect. 

1.  Antiseptic  and  Drying. 

Pulv.  Boric  Acid. 

Xeroform  and  Boric  Acid  (1  to  4). 

Bismuth  Subnitrate. 

Bolus  Alba. 

Aristol. 

Pulverized  boric  acid  is  used  as  a  mild  antiseptic  and  drjang  powder.  It.  is 
bland  and  can  hardly  cause  irritation  even  with  children.  Xeroform  and  boric 
acid  (1  to  4)  is  preferable  when  a  stronger  antiseptic  powder  is  desired,  in  fact,  it 
is  the  powder  I  ordinarily  use,  except  when  some  special  astringent  or  anesthetic 
effect  is  desired.  Xeroform  has  proven  a  very  satisfactory  substitute  for  iodo- 
form. Its  action  in  stimulating  healthy  granulation,  is  very  much  like  iodoform 
and  it  has  practically  no  odor.  It  is  I  think  just  as  effective,  if  not  more  so,  than 
the  other  iodoform  substitutes  and  less  expensive. 

Bolus  Alba  (the  ordinary  yeast  germs  dried)  has  been  highly  recommended  as 
a  vaginal  application  in  cases  of  leucorrhoea,  with  the  idea  that  the  yeast  fungi  in- 
hibit the  growth  of  other  bacteria.  Gonorrhoeal  infections  are  probably  favor- 
ably influenced  by  this  powder.  Ceriviscine,  a  special  preparation  of  the  dried 
yeast  plant,  has  been  put  upon  the  American  market  and  numerous  favorable  re- 
sults have  been  reported. 

2.  Anesthetic  powders. 

Orthofoim,  Xeroform  and  Boric  Acid  (1-1-4). 
Chloretone,  Xeroform  and  Boric  Acid  (1-1-4). 

Orthoform  is  a  powder  that  is  decidedly  anesthetic  and  for  that  reason  is  advan- 
tageously combined  with  powders  used  in  the  treatment  of  painful  affections  of  ex- 
ternal genitals.  Vagina  and  cervix.  The  anesthetic  effect  is,  of  course,  most  marked 
when  the  powder  is  used  pure,  but,  Uke  cocaine,  it  has  a  devitalizing  effect  on  poorly 


324  GYNECOLOGIC  TREATMENT 

nourished  tissues  and  may  cause  superficial  sloughing  if  used  too  strong.  I  have 
had  such  an  experience  with  it  in  treating  superficial  abrasions  due  to  senile  pru- 
ritis  vulvae — the  orthoform,  when  dusted  on  pure,  causing  the  abrasions  to  become 
very  extensive  instead  of  smaller.  A  similar  experience,  in  a  patient  past  the 
menopause,  was  related  to  me  by  one  of  my  colleagues. 

Chloretone  can  be  used  to  advantage  whenever  there  is  pruritis  or  a  sense  of 
soreness  in  the  vagina  or  about  the  external  genitals.  It  is  very  satisfactory  as  a 
dusting  powder  to  painful  ulcers,  chancroidal  and  otherwise.  As  a  dusting  powder, 
it  is  diluted  with  a  bland  powder  and  combined  with  an  antiseptic  powder  as  above 
indicated. 

TABLETS. 

Compressed  tablets  containing  antiseptic  or  astringent  or  anesthetic  drugs,  are 
put  up  for  vaginal  use.  They  may  be  introduced  to  the  upper  part  of  the  vagina 
by  the  patient,  either  following  a  douche  or  without  a  douche,  once  or  twice  daily 
or  more  often  as  directed  by  the  physician. 

Tablets  of  various  formulae  for  vaginal  use  may  be  obtained.  Several  of  them 
are  given  in  the  Appendix.  They  are  very  convenient  in  cases  where  it  is  desir- 
able to  have  the  patient  use  some  drug  between  the  office  treatments  or  where  the 
patient  can  not  come  to  the  physician  or  be  seen  by  him  often  enough  for  regular 
treatment.  They  are  not  as  effective,  however,  as  powder  apphcations  made  with 
speculum  exposure  of  the  affected  area  and  held  in  place  by  a  tampon,  as  in  office 
treatment.  In  prescribing  tablets  use  only  those  put  up  by  a  reliable  house,  so 
that  you  can  depend  on  the  stated  formula  and  know  just  what  you  are  using. 

The  effect  of  these  tablets,  dissolved  in  the  vagina,  as  of  other  vaginal  medica- 
tion, is  of  course  only  local  (limited  to  superficial  effect  on  the  vagina  and  cervix) 
and  has  practically  no  influence  on  deep-seated  or  serious  vaginal  or  uterine  or  peri- 
uterine lesions.  Tablets  of  various  shapes  and  alleged  formulae  and  called  by 
fancy  names,  are  put  up  for  vaginal  use  by  patent  medicine  venders  and  peddled 
from  house  to  house  by  women  agents.  They  are  put  forth  as  wonderful  discov- 
eries that  will  cure  all  ''female  diseases,"  and  Uke  other  alleged  "wonderful  dis- 
coveries" they  deceive  many  a  poor  woman  with  unfounded  hopes,  the  falseness 
of  which  in  serious  diseases  she  of  cen  discovers  only  when  the  disease  is  past  cure. 
It  is  another  case  of  "blind  leading  the  blind"  or,  worse  still,  of  avarice  leading 
the  blind. 

VAGINAL  SUPPOSITORIES  AND  CONES, 

Vaginal  suppositories  furnish  another  method  of  applying  medicine  to  the  va- 
ginal wall  and  cervix. 

In  vaginal  suppositories,  the  active  ingredient  is  incorporated  with  coca  butter 
or  othei-  suitable  material  which  melts  in  the  vagina.  Vaginal  suppositories  are 
used  principally  in  the  treatment  of  chronic  vaginitis  in  children,  in  cases  in  which 
it  is  difficult  or  impracticable  to  employ  the  ordinary  and  more  effective  methods 
of  vaginal  treatment.  Formulae  of  vaginal  suppositories  are  given  in  the  Ap 
pendix- 


USE  OP  TAMPO^S  325 


TAMPONS. 


A  vaginal  tampon  is  simply  a  piece  of  absorbent  cotton  or  common  cotton  or 
wool  or  gauze,  of  the  desired  size  and  shape,  with  a  short  string  attached, so  that 
the  tampon  may  be  removed  from  the  vagina  by  the  patient  after  a  specified  time. 

One  way  to  make  a  cotton  tampon  is  to  take  a  rather  thick  piece  of  cotton 
(common  cotton  or  absorbent  cotton)  of  the  required  length  and  width  and  thick- 
ness and  tie  one  end  of  a  strong  string  firmly  about  the  middle.  Fold  the  cotton  at 
the  place  where  the  string  is  tied.  This  brings  the  free  ends  together.  If  it  is  de- 
sired to  use  a  solution,  the  free  ends  are  dipped  in  it.  If  it  is  desired  to  use  powder, 
the  free  ends  are  spread  out  so  as  to  make  a  depression  in  which  the  powder  is 
placed.  This  end  of  the  tampon  is  then  caught  \\'ith  the  long  uterine  dressing 
forceps  and  carried  up  to  the  cervix.  Leave  the  string  long  enough  so  that  the  end 
will  project  from  the  vagina,  that  the  patient  may  easily  catch  it  and  remove  the 
tampon  at  the  end  of  tw^elve  to  twenty-four  hours  as  directed.  It  is  well  to  make 
the  string  into  a  loop,  as  indicated  in  Fig.  4.50.  Tampons  made  of  surgical  wool 
are  preferable  when  the  principal  effect  desired  is  support,  as  they  are  much  more 
elastic  than  the  cotton  and  retain  their  elasticity  longer.  In  some  cases  the  wool 
proves  to  be  irritating  to  the  vaginal  walls.  To  prevent  this  and  yet  secure  the 
springyness  imparted  by  the  wool,  the  wool  tampon  may  be  covered  with  a  thin 
layer  of  common  cotton. 

It  is  a  good  plan  to  keep  prepared,  ready  for  use,  a  number  of  tampons  of  different 
sizes.  They  may  be  prepared  during  leisure  and  they  are  then  ready  when  needed, 
and  thus  is  saved  considerable  time  and  inconvenience. 

When  the  vagina  is  tamponed  with  a  strip  of  gauze  or  ■v\ith  cotton  balls  without 
strings,  it  is  referred  to  as  a  vaginal  tamponade.  I  have  included  all  these  pack- 
ings under  the  general  term  "tampons." 

Tampons  of  cotton  or  wool  or  gauze  or  vaginal  packings  of  the  same,  are  used 
for  the  following  purposes. 

1.  To  secure  the  effect  of  drugs  incorporated  in  the  gauze  or  cotton  or  held  in 
place  by  them. 

2.  To  occlude  the  vagina  after  operations  in  its  upper  part. 

3.  To  stop  hemorrhage. 

4.  To  keep  inflamed  surfaces  separated. 

5.  To  support  the  pelvic  organs. 

Tampons  are  much  used  for  holding  medicine  against  the  cervix  and  vaginal 
vault.  If  the  medicine  is  in  solution,  for  example,  one  of  the  glycerine  prepar- 
ations, the  end  of  the  tampon  is  dipped  into  the  solution  and  then  applied  to  the 
vaginal  vault  and  left  there,  to  be  removed  by  the  patient  after  twelve  to  twenty- 
four  hours.  If  the  medicine  is  a  powder,  it  is  dusted  freely  about  the  cervix  and 
some  of  it  is  placed  on  the  end  of  the  tampon,  which  is  introduced  as  before. 

When  used  to  occlude  the  vagina  after  an  operation,  the  gauze  or  cotton  is  simply 
a  surgical  dressing,  the  same  as  when  applied  to  an  external  wound.  The  gauze 
or  cotton  may  be  simply  sterile  or  it  may  be  impregnated  with  some  antiseptic,  as 
in  bichloride  gauze,  iodoform  gauze,  etc. 


326  GYNECOLOGIC  TREATMENT 

When  gauze  or  cotton  is  used  to  check  hemorrhage  it  should  first  be  wet  in  some 
antiseptic  solution  and  then  squeezed  as  dry  as  possible  before  being  packed  into 


Fig.  450.  Preparation  of  Tampons,  a.  A  piece  of  cotton  of  the  required  size  with  a  strong  string  tied  about 
the  middle  and  also  a  loop  tied.  b.  The  same,  with  the  ends  folded  up  preparatory  to  receiving  powder  in  the 
hollow  formed  there  or  to  being  dipped  into  an  application-solution,  c.  Another  satisfactory  way  of  making  a 
tampon.  The  piece  of  cotton  is  folded  and  the  ends  are  tied  together  and  the  string  looped,  d.  .\  small  bowl 
containing  tampons  ready  for  use. 

the  vagina.     Used  in  thi«  way  it  makes  a  much  more  effective  hemostatic  than 
when  used  perfectly  dry. 


USE  OF  TAMPON-CAPSULES 


327 


For  keeping  inflamed  surfaces  separated,  l:iiiipons  of  cotton  or  gauze-strips  are 
used  in  the  various  forms  of  vaginitis. 

To  support  the  uterus  or  hold  it  in  position,  dry  gauze  or  cotton  or  wool  is  used. 
Wool  has  more  "spring"  in  it  than  cotton  or  gauze,  consequently  a  wool  tani])()n 
is  the  best  in  cases  where  only  support  is  required.  Sometimes  the  wool  tampon 
irritates  the  vagina,  in  which  case  it  may  be  covered  with  a  thin  layer  of  cotton  as 
before  mentioned.  When  cotton  is  used  for  supporting  tampons,  ordinary  cotton 
is  better  than  absorbent  cotton,  as  the  latter  absorbs  fluids  rapidly  and  soon  loses 
its  elasticity.  A  tampon  or  tamponade  for  support  should  be  put  in  with  the 
patient  in  the  Sims  posture  or  in  the  knee-chest  posture. 


Fig.  451.  Tampon-Capsules.  a.  Large  size.  b.  Small  size.  c.  The  cap  removed,  showmg  the  tampon. 
d.  A  tampon-capsule  prepared,  ready  for  introduction.  The  cap  was  removed  and  the  medicme  poured  into  tne 
cap,  which  was  then  replaced.     The  dark  ichthyol  mixture  shows  through  the  transparent  cap. 


TAMPON-CAPSULES. 

Ordinarily,  all  tampons  are  introduced  by  the  physician.  When,  however,  it  is 
advisable  that  tampons  be  applied  at  home  by  the  patient,  between  the  office  visits 
or  in  conditions  in  which  the  patient  can  not  well  come  to  the  office,  the  tampon- 
capsule  may  be  used.  The  tampon-capsule  is  a  large  capsule  of  special  design 
containing  a  plain  wool  tampon  with  a  string  attached.  There  are  two  sizes  (Fig. 
451).  They  come  in  boxes  of  a  dozen  and  may  be  purchased  from  the  diuggist  or 
wholesale  drug-houses.  They  are  convenient  for  use  immediately  after  the  hot 
douche,  to  secure  hygroscopic  effect.    Just  before  use,  the  patient  removes  the  cap 


328  GYNECOLOGIC  TREATMENT 

from  the  capsule,  pours  in  about  a  half  a  teaspoonful  of  any  desired  medicine 
(usually  boro-glycerine  or  ichthyol-glycerine),  replaces  the  cap  and  introduces 
the  capsule,  medicated  end  first,  up  to  the  vaginal  vault.  Here  the  capsule  soon 
melts,  liberating  the  medicine  and  tampon,  and  the  latter  holds  theformer  in  place. 

PESSARIES. 

Pessaries  are  appliances  for  introduction  into  the  vagina  for  the  purpose  of  hold- 
ing the  uterus  or  vaginal  wall  in  proper  position.  They  are  made  of  hard  rubber 
or  soft  rubber,  usually  the  former.  Those  made  of  soft  rubber  are  generall}^  hol- 
low and  contain  air  or  flexible  mre.  Occasionally  a  pessary  is  made  of  glass  or 
block-tin  or  some  other  material. 

Pessaries  are  used  principally  for  the  following  affections. 
For  Backward  Displacement  of  the  Uterus. 
For  Prolapse  of  the  Uterus. 
For  Prolapse  of  the  Anterior  or  Posterior  Vaginal  Wall. 

For  Backward  Displacement  of  Uterus. 

In  retrodisplacement  of  the  uterus  the  pessary  is  used  after  replacement,  to  held 
the  uterus  in  proper  position.  Occasionally  a  pessary  is  used  to  support  the  uterus 
somewhat  when  complete  replacement  is  not  practicable. 

Varieties  Used. 

nnumerable  forms  have  been  recommended,  and  to  attempt  to  mention  all  of 
them  would  be  a  waste  of  time.  The  following  four  varieties  are  the  principal  ones 
used  at  present  in  the  treatment  of  retrodisplacement,  and  they  are  sufficient  in 
practically  all  cases  in  which  a  pessary  is  the  preferable  method  of  treatment. 


Fig.  452.     A.   Tlie  Hodge  Pessary.     B.  Tlie  Albert  Smith  Pessary.      C.  The  Thomas  Pessary. 

1.  Hodge  Pessary  (Fig.  452,  A).  This  pessary,  devised  by  Hugh  L.  Hodge, 
Professor  of  Diseases  of  Women  in  the  University  of  Pennsylvania  from  1835  to 
1863,  may  be  taken  as  the  type  of  the  hard-rul)ber  ring  pessaries.  It  is  the  original 
model  from  which  nearly  all  other  pessaries  of  that  character  descended.   It  is 


PESSARIES  FOR  RETRODISPLACEMENT 


329 


stil  much  used  and,  as  explained  later,  is  the  most  suitable  one  for  certain  con- 
ditions. 

2.  Albert  Smith  Pessary  (Fig.  452,  B).  Albert  H.  Smith  modified  the  Hodge 
Pessary  in  two  important  particulars.  He  narrowed  the  anterior  end  so  that  it 
fits  well  up  into  the  narrow  portion  of  the  pubic  arch,  the  point  projecting  slightly 
into  the  arch.  This  tends  to  keep  the  pessary  from  turning  or  slipping  about  in  the 
vagina  and  at  the  same  time  causes  the  anterior  part  of  the  pessary  to  lie  higher — 
SO  that  it  is  out  of  the  way  and  does  not  interfere  with  coitus  or  with  the  introduc- 
tion of  a  douche-nozzle.  His  other  modification  was  a  lengthening  of  the  posterior 
arm  of  the  pessary.  This  pushes  the  posterior  vaginal  fornix  further  upward  and 
backward,  thus  increasing  the  ability  of  the  pessary  to  hold  the  cervix  uteri  well 
back  in  the  pelvis. 

3.  Thomas  Pessary  (Fig.  452,  C),  sometimes  called  the  Smith-Thomas  pessary. 
T.  Gaillard  Thomas  modified  the  Smith  pessary(which  was  itself  a  modification  of 
the  Hodge  pessary)  by  thickening  the  posterior  end  into  a  bulbous  enlargement. 
This  distributes  the  pressure  over  a  larger  surface  of  the  posterior  fornix,  and  in 
that  way  tends  to  prevent  pressure  injury  of  the  vaginal  vault  at  that  point. 

4.  Inflated  Ring  Pessary,  to  be  described  later. 

Action  of  the  Pessary. 

The  action  of  the  Hodge  pessary  and  its  modifications,  as  ordinaiily  used  in  a 
ease  of  retrodisplacement,  is  to  hold  the  cervix  back  in  the  hollow  of  the  sacrum. 

As  long  as  the  cervix  is  held  well  back  in  the  pelvis, the  fundus  uteri  will  stay  forward 
where  it  belongs.  The  pessary  holds  the  cervix  uteri  back  in  place  by  holding  back 
the  posterior  vaginal  vault  (to  which  the  cervix  is  closely  attached!  and  also  by 
pushing  upward    and   backward  on 

the    sacro-uterine    ligaments,    thus       [— — -■  iA'M^^  abi1ft«*<?f'^'-: 

putting  them  on  the  stretch.  To  ac- 
complish this,  the  anterior  portion 
of  the  pessary  must  have  a  rather 
firm  support,  which  it  gets  from 
the  pul^ic  arch  (with  intervening 
soft  tissues)  and  the  pelvic  floor. 

The  action   of  the   pessary,  ^\^th 
its  many  curves,  seems  to  be  a  veri- 
table puzzle  to  many  students  and 
to  not  a  few  practitioners,  yet  it  is 
clear    enough    when    properly     ap- 
proached and  studied.     In  order  to 
make  the  matter  clear  to  my  classes 
in  a  short  explanation,  I  am  accus- 
tomed to  approach  the  subject  syn- 
thetically so  to  speak,  i.  e.,  to  grad- 
ually build  up  in    mind    such  a  pes-  ^ig.  453.     The  Pessary  in  Place.    The  action  of  the 
Sary.       We    know    that  after  a  mOV-           pessarj' is  to  hold  the  posterior  vaginal  fornix,  and witlj 
•11           i        T       1           1       J              11                     it    the   attached    cervix,  well  backward  and  upward  it. 
able  retrodisplaced  Uterus   has  been          the  pelvis.     (Skenc^J>iseases  o/ Women.) 


330  GYNECOLOGIC  TREATMENT 

replaced,  if  we  keep  the  cervix  well  back  in  the  pelvic  cavity,  that  is,  a  certain 
distance  from  the  vaginal  outlet,  the  fundus  will  stay  forward  (Fig.  453).  Sup- 
pose then  that  we  introduce  a  straight  stick  that  reaches  from  the  public  arch  to 
the  posterior  vaginal  vault.  Now  as  long  as  the  anterior  end  of  the  stick  is  sup- 
ported by  the  pubic  arch,  neither  the  posterior  vaginal  fornix  nor  the  cervix, 
which  is  closely  attached  to  it,  can  approach  the  vaginal  outlet.  The  cervix  can 
move  up  and  down  through  a  small  arc,  but  it  can  not  come  any  nearer  the 
vaginal  outlet  and  consequently  as  the  cervix  is  held  well  back  in  the  pelvis  the 
fundus  uteri  stays  forward. 

This  is  practically  the  action  of  the  pessary.  It  takes  its  fixed  point  of  support 
from  the  pubic  arch  (the  soft  tissues  intervening) ,  being  held  up  against  the  narrow 
part  of  the  arch  by  the  pelvic  floor.  As  long  as  the  anterior  end  of  the  pessary  is 
properly  supported  (held  stationary)  the  posterior  end  holds  the  posterior  vaginal 
vault  and  the  attached  cervix  well  back  in  the  pelvis.  The  ring  shape  of  the  pes- 
sary and  the  various  curves  are  simply  to  adjust  it  comfortably  to  the  adjacent 
structures.  The  open  ring  permits  the  pessary  to  lie  up  well  out  of  the  way  in  the 
lateral  angles  of  the  vaginal  canal  and  also  permits  the  cervix  to  project  through 
the  pessary  and  the  uterine  secretions  to  flow  outward  without  hindrance.  The 
marked  upward  bend  of  the  posterior  portion  of  the  pessary  increases  its  ability  to 
push  the  posterior  vaginal  fornix  upward  and  backward  and  put  the  sacro-uterine 
ligaments  on  the  stretch.  The  long  upward  curve  of  the  front  part  of  the  pessary 
with  the  narrow  anterior  end  permits  the  anterior  end  to  lie  up  out  of  the  way  in 
the  narrow  part  of  the  arch,  and  also  furnishes  a  slope  against  which  the  perineum 
and  front  part  of  the  pelvic  floor  acts  advantageously,  helping  to  support  the  pes- 
sary in  both  an  upward  and  backward  direction  and  thus  taking  some  of  the  pres- 
sure off  the  extreme  anterior  end.  If  all  the  pressure  on  the  pessary  were  trans- 
mitted to  the  very  end,  it  would  cause  pain  by  pinching  the  soft  tissues  between 
the  pessary  and  the  bony  arch.  With  the  long  steep  upward  curve,  however,  a 
largo  part  of  the  downward  and  forward  pressure  is  borne  by  the  pelvic  floor.  The 
little  transverse  notch  or  downward  dip  at  the  anterior  end  of  the  pessary  is  to 
prevent  pressure  on  the  urethra  as  the  pessary  lies  well  up  in  the  angle  of  the  pubic 
arch. 

The  two  principal  factors  in  the  support  of  such  a  pessary  are  the  pubic  arch 
and  the  pelvic  floor.  As  to  just,  which  furnishes  the  most  support,  it  is  hard  to 
say — probably  there  is  much  variation  in  different  cases,  depending  on  the  con- 
formation of  the  parts  and  the  shape  of  the  pessary. 

When  the  pelvic  floor  is  severely  torn  it  permits  the  pessary  to  sink  lower  in  the 
pelvis.  The  anterior  narrow  end  lies  at  a  wide  part  of  the  arch,  a  part  too  wide  to 
furnish  support  for  it  and  it  slips  outside  a  short  distance.  This  permits  the  cervix 
to  come  forward  and  then  'the  fundus  goes  backward.  Now  in  such  a  case,  if  we 
use  a  pessary  with  a  wider  anterior  end  (e.  g.,  the  regular  Hodge  pessary)  it,  being 
wider,  impinges  on  the  sides  of  the  arch  and  holds  the  cervix  back  where  it  belongs. 
In  very  severe  laceration,  the  marked  relaxation  of  the  pelvic  floor  allows  the  pes- 
sary to  come  so  low — to  such  a  very  wide  part  of  the  arch — that  not  even  the  Hodge 
pessary  will  stay  in.  In  such  a  case  some  temporary  relief  may  be  given  by  other 
styles  of  pessary  to  bo  mentionoc]  later. 


KIND  OF  PESSARY  REQUIRED  IN  VARIOUS  CONDITIONS  331 

Selection  of  Pessary. 

The  selection  of  the  pessary  best  adapted  to  a  i^articulur  case  concerns  the  style, 
size  and  special  modifications. 

As  to  style  or  form,  in  retrodisp  acement  I  prefer  the  Tliomas  pessary  in  all  but 
exceptional  cases.     The  advantages  of  this  form  are: — 

a.  Narrow  anterior  end  that  lies  well  up  out  of  the  way.  There  is  little  or  no 
interference  with  coitus  or  with  the  introduction  of  the  douche-nozzle. 

b.  Long  steep  anterior  slope  on  which  the  pelvic  floor  can  act  to  advantage  in 
assisting  in  the  support  of  the  pessary. 

c.  Long  posterior  arm,  which  tends  to  keep  the  posterior  vaginal  fornix  well  up. 

d.  Thick  posterior  end,  which  distributes  the  pressure  over  a  wide  surface  of  the 
posterior  vaginal  fornix  and  thus  prevents  injurious  pressure  or  ulceration  at  any 
point. 

The  exceptional  cases  in  which  the  Thomas  pessary  is  not  satisfactory,  are  as 
follows: — 

1.  Where  there  is  a  severe  laceration  of  the  pelvic  floor.  In  these  cases  a  pes- 
sary with  a  wider  anterior  end  is  required,  as  previously  explained.  Here  the  regular 
Hodge  pessary  is  usually  the  preferable  one.  In  lacerations  of  extreme  severity, 
where  the  parts  are  so  relaxed  that  neither  the  Hodge  or  Smith  or  Thomas  pessary 
Avill  stay  in,  the  inflated  ring  pessary  or  one  of  the  other  forms  mentioned  under 
prolapse  may  give  some  temporary  relief.  For  permanent  relief  in  such  a  case 
operative  measures  are  required. 

2.  Where  the  posterior  vaginal  fornix  is  too  small  or  shallow  to  accommodate 
the  large  bulbous  end.  In  such  a  case  the  Smith  or  the  Hodge  pessaiy  may  be 
used.  In  each  of  these  the  posterior  bar  is  of  small  diameter  and  will  fit  into  a 
small  posterior  fornix.  If  the  pelvic  floor  is  not  too  badly  torn  the  Smith  pessary 
is  the  preferable  one  of  the  two,  as  it  has  the  narrow  anterior  end  and  the  long  pos- 
terior arm. 

3.  When  there  are  painful  inflammatory  lesions  about  the  uterus  or  a  prolapsed 
and  tender  ovary.  In  some  of  these  cases  the  pessary  may  be  worn  without  dis- 
comfort after  the  parts  have  been  held  in  place  by  tampons  for  a  few  days.  In 
others, the  tenderness  persists  and  any  form  of  pessary  which  pushes  well  up  be- 
hind the  cervix  causes  pain  and  hence  can  not  be  worn.  In  such  cases  the  inflated 
ring  pessary  sometimes  gives  considerable  relief  by  diminishing  the  dragging  of  the 
heavy  uterus  on  the  inflamed  adnexa  and  broad  ligaments.  As  a  rule,  however, 
in  such  cases  time  spent  with  pessaries  is  time  wasted,  as  far  as  any  permanent 
relief  is  concerned. 

As  to  the  size  of  pessary  to  be  selected,  the  approximate  length  may  be  deter- 
mined by  measuring  with  the  examining  fingers  the  distance  from  the  posterior 
vaginal  vault  (pushed  well  up)  to  the  pubic  arch.  The  length  of  the  pessar}' 
should  be  a  trifle  less  than  this.  The  width  of  pessary  which  the  vagina  will  ac- 
commodate may  be  determined  approximately  by  the  apparent  roominess  of  the 
\^agina  as  felt  on  vaginal  palpation.  A  special  maneuver  for  this  purpose  is  to  in- 
troduce the  two  examining  fingers  to  the  upper  part  of  tlie  vagina,  separate  them 
laterally  as  far  ns  the  vaginal  walls  will  permit  and  then  withdraw  them  in  the 


332  GYNECOLOGIC  TREATMENT 

antero-posterior  diameter  (the  largest  diameter  of  the  vaginal  outlet),  retaining 
them  as  nearly  as  possible  in  the  original  position. 

However,  the  size  of  pessary  that  will  keep  the  uterus  in  position  with  the  least 
discomfort  can  be  determined  certainly  only  by  trial,  and  several  pessaries  may 
have  to  be  worn  for  a  short  time  before  the  most  satisfactory  one  for  that  partic- 
ular case  is  settled  upon.  A  pessary  that  is  too  small,  fails  to  hold  the  uterus  in 
position  and  tends  to  slip  out.  A  pessary  that  is  too  large,  causes  pain.  It  is  better 
to  give  too  small  than  too  large  a  pessary,  as  the  latter  may  cause  severe  pain  after 
it  has  been  in  place  a  day  or  two,  and  if  the  patient  is  a  long  way  from  the  physician 
and  cannot  succeed  in  removing  the  pessary  herself,  she  may  experience  much 
suffering. 

The  special  modifications  refer  to  slight  changes  in  shape  from  the  regular  form, 
occasionally  required  to  make  the  pessary  more  comfortable  or  more  satisfactory 
in  retaining  the  uterus  in  position. 

1.  General  Narrowing  of  the  pessary.  The  pessaries  as  purchased  maintain  a 
ratio  between  the  width  and  the  length  (the  longer  the  pessary  the  wider  it  is). 
As  a  rule  this  is  desirable.  In  some  cases,  however,  the  vaginal  opening  is  too 
small  to  admit  a  pessary  of  sufficient  length.  To  overcome  this  difficulty  drop  the 
pessary  in  hot  water  for  a  moment,  until  it  becomes  slightly  pliable,  then  remove 
it  with  a  forceps,  grasp  it  with  a  towel  and  squeeze  it  so  as  to  narrow  it  laterally  to 
the  required  extent,  and  hold  it  thus  until  it  cools.  The  cooling  may  be  hastened 
by  holding  it  in  cold  water.  Do  not  keep  it  very  long  in  the  hot  water  or  it  will 
become  so  pliable  that  it  flattens  into  a  simple  ring,  and  all  the  characteristic  curves 
are  lost. 

2.  Local  Bending.  Occasionally  it  is  desired  to  bend  a  hard-rubber  pessary  at 
some  particular  point,  so  as  to  change  an  ordinary  curve  to  an  unusual  one  or  to 
change  one  form  of  pessary  to  resemble  another  form,  which  is  needed  but  is  not  on 
hand.  To  make  these  local  bendings,  coat  that  part  of  the  pessary  to  be  bent  lib- 
erally with  vaseline  or  other  ointment  and  hold  it  high  above  the  flame  of  an  alcohol 
lamp  orBunsen  burner.  Hold  it  close  enough  to  the  flame  to  heat  the  pessary  well 
at  the  exact  area  it  is  desired  to  bend  but  not  close  enough  to  burn  off  the  ointment. 
In  a  few  moments  the  pessary  is  softened  sufficiently  to  permit  bending.  If  the 
pessary  is  brought  too  close  to  the  flame,  it  is  burned  and  the  smooth  surface 
roughened. 

In  1859,  J.  Marion  Sims  introduced  the  block-tin  modification  of  the  Hodge  pes- 
sary, the  advantage  of  this  material  being  that  it  is  sufficiently  pliable  to  be  moulded 
to  any  shape  and  yet  firm  enough  to  hold  the  shape  given  it.  The  block-tin  pes- 
sary was  the  favorite  with  Dr.  T.  A.  Emmet  and  was  highly  recommended  by  him, 
but  it  is  not  so  frequently  used  at  the  present  time.  Ordinarily  the  hard-rubber 
pessary  is  preferable.. 

Pessary  Used  Only  After  Replacement. 

The  pessary  is  ordinarily  not  used  until  the  uterus  has  been  brought  forward. 
The  pessary  is  not,  as  many  suppose,  used  to  push  the  fundus  uteri  forward, 
neither  is  it  used  to  prop  the  fundus  forward.     The  pessary  has  nothing  to  do 


THE  INTRODUCTION  OF  THE  PESSARY  333 

directly  with  this  part  of  the  uterus.  All  the  pessary  does  is  to  hold  the  cervix 
well  back  in  the  pelvis,  as  previously  explained,  and  then  in  the  ordinary  state  of 
affairs  the  fundus  must  stay  forward. 

There  are  some  exceptions  to  the  rule  that  a  pessary  is  used  only  after  replace- 
ment. In  some  cases  of  roomy  pelvis,  in  which  it  is  difficult  to  raise  a  movable 
fundus  uteri  because  it  gets  out  of  reach,  a  pessary  may  be  used  somewhat  as  an 
extension  to  the  finger,  to  help  raise  the  fundus  within  reach  of  the  abdominal 
fingers.  Hodge,  in  describing  the  use  of  his  pessary,  mentions  it  as  a  lever  for  re- 
placing the  uterus.  He  directs  that  the  pessary  be  introduced  and  then  by  de- 
pressing the  anterior  end,  the  posterior  end  is  thrown  upward  carrying  the  fundus 
with  it.  This  is  called  the  lever  action  of  the  pessary,  the  pelvic  floor  serving  as 
the  fulcrum,  and  he  refers  to  his  pessary  as  the  "  lever  pessary. "  But  this  action 
of  this  pessary  is  seldom  employed  now,  as  there  are  more  effective  methods  of  re- 
placement. 

Again,  in  a  case  of  movable  uterus  which  can  not  be  brought  forward  satisfac- 
torily, if  a  pessary  be  introduced  and  the  patient  instructed  to  take  the  knee-chest 
posture  twice  daily,  the  uterus  may  be  found  forward  at  the  next  examination  a 
few  days  later 

Again,  in  some  cases  where  the  uterus  can  be  raised  considerably  but  can  not  be 
brought  forward,  a  pessary  introduced  and  worn  just  as  if  the  uterus  were  forward, 
will,  in  conjunction  ^\ith  the  knee-chest  posture  morning  and  evening,  give  the 
patient  some  relief — indicating  that  in  that  particular  case  the  symptoms  are  due 
not  so  much  to  backward  displacement  yer  se  as  to  the  sinking  of  the  uterus  with 
the  consequent  disturbance  of  the  circulation,  which  is  relieved  by  the  pessary  in 
spite  of  the  fact  that  the  uterus  is  still  in  retrodisplacement.  It  is  this  holding  up 
of  the  heavy  uterus  and  the  relief  of  the  slight  prolapse  complicating  the  retro- 
displacement,  that  accounts  for  the  decided  relief  often  secured  by  the  use  of  the 
inflated  ring  pessary  in  cases  of  unreplaced  retrodisplaced  uterus. 


Introduction  of  the  Pessary. 

Ordinarily  the  pessary  is  introduced  with  the  patient  in  the  dorsal  posture, 
immediately  after  the  uterus  has  been  brought  forward  by  bimanual  reposition  as 
described  in  chapter  vii. 

Before  introducing  a  pessary,  cleanse  it  thoroughly  in  an  antiseptic  solution  and 
then  lubricate  it  with  a  suitable  ointment.  In  introducing  it  into  the  vaginal  open- 
ing, if  the  opening  seems  rather  small,  put  one  finger  in  the  vagina  and  depress  the 
perineum  strongly  to  make  room  for  the  pessary.  Remember,  in  introducing  a 
pessary  or  speculum  or  the  examining  fingers  into  the  vagina,  if  the  opening  seems 
small  and  more  room  is  desired,  the  pressure  must  always  be  made  backward,  de- 
pressing the  perineum.  The  least  pressure  forward  will  pinch  the  tissues  against 
the  pubic  arch. 

The  introduction  or  placing  of  the  pessary  is  carried  out  as  follows:  Hold  the 
pessary  by  the  anterior  end,  depress  the  perineum  well  with  one  finger  (Fig.  454) 
and  introduce  the  posterior  end  with  the  breadth  of  the  pessary  lying  in  the  an- 


334 


GYNECOLOGIC  TREATMENT 


tero-posterior  diameter,  which  is  the  largest  diameter  of  the  opening.  The  pes- 
sary should  be  held  somewhat  obliquely  so  as  not  to  make  painful  pressure  on  the 
urethra  (Fig.  455).     When  the  pessary  is  about  half  way  in  (Fig.  456)  turn  it  so 


Fig.  454.     Introducing   the    Pejsary. 
pressing  the  perineum. 


First  step — de-  ^  Fig.  455.  Introducing  the  Pe.ssary  tluougli  the 
vaginal  opening.  The  width  of  the  pessary  lies  in 
the  antero-posterior  diameter  of  the  opening,  which 
is  the  long  diameter,  but  is  turned  somewhat  oblique- 
ly to  avoid  the  urethra. 


that  the  breadth  of  the  pessary  lies  laterally  (Fig.  457)  and  the  posterior  arm  is 
directed  upward.  Then  push  the  pessary  along  until  it  will  not  go  any  further. 
It  stops  because  the  posterior  end  is  against  the  anterior  lip  of  the  cervix.  Then 
introduce  a  finger  into  the  vagina  beneath  the  pessary,  catch  the  posterior  bar  with 
the  finger  tip  (Fig.  458)  and  depress  it  (Fig.  459)  and  then  push  the  pessary  past 
the  cervix.     Fig.  453  shows  the  pessary  in  place. 


THE  INTRODUCTION  OF  THE  PESSARY 


335 


After  the  pessary  is  in  place  it  is  well  to  have  the  patient  walk  about  the  room 
a  little,  to  see  if  tliere  is  any  discomfort.  If  there  is  any  decided  ])ain  or  marked 
discomfort,  try  a  smaller  size  or  another  form. 

In  those  cases  in  which  it  is  necessary  to  use  the  knee-chest  posture  to  effect  re- 


Fig.  456.      Introducing  the   Pessary.       The  pessary 
is  now  well  within  the  vagina  and  ready  for  turning. 


Fig.  457.  Introducing  the  Pessary.  The  pessary  is 
turned  so  the  width  lies  transversely,  for  the  transverse 
diameter  is  the  long  diameter  of  the  vaginal  canal, 
though  not  of  the  vaginal  entrance.  The  pessary  is 
then  pushed  in  until  its  further  progress  is  stopped  by 
the  cervix. 


position  and  also  in  those  cases  in  which  it  is  thought  advisable  to  use  a  pessary 
even  though  the  uterus  can  not  be  brought  well  forward,  it  is  advisable  to  intro- 
duce the  pessary  with  the  patient  in  the  knee-chest  posture. 


336 


GYNECOLOGIC  TREATMENT 


Instructions  to  Patient  with  Pessary. 

The  care  of  a  patient  having  a  pessary  in  place,  includes  the  following  points: — 
Visits  to  the  Physician.  When  the  pessary  is  introduced  the  patient  is  directed 
to  leturn  in  about  three  days.  If  the  pessary  is  proving  satisfactory  then,  she 
need  not  return  again  for  a  week.  If  everything  is  going  well  at  this  third  visit, 
she  need  not  return,  except  once  every  four  to  six  weeks  to  have  the  pessary  re- 
moved and  thoroughly  cleansed  and  replaced. 


Fig.  458.     Introducing  the  Pessary.     The  inde.K  finger  is  passed  to  tiie  top  of   the  posterior  end,  whicli  is  tliea 
depressed  until  it  can  be  pushed  past  the  cervix,  as  shown  in  Fig.  459. 


There  is  always  more  or  less  uncertainty  for  the  first  week  or  so,  as  to  just  how 
the  pelvic  structures  will  accommodate  themselves  to  a  pessary.  For  that  reason 
it  is  well  to  instruct  the  patient  to  return  at  once  if  any  unusual  pain  is  felt  or  if  the 
pessary  appears  to  slip  out  of  position.  But  the  patient  should  return  in  three  or 
four  days,  even  though  she  has  no  particular  disturbance,  for  the  uterus  may  have 
settled  back  into  its  old  malposition. 


DIRECTIONS  TO  PATIENT  ^^  ITU  PESSARY 


337 


At  this  second  visit,  inquire  if  the  patient  has  noticed  any  protrusion  or  slipping 
of  the  pessary  or  has  luid  any  pain  or  cU.sconifort  from  the  pessary.  A  pessaiT 
which  is  entirely  satisfactory  should  give  little  or  no  sensation  of  its  presence,  in 
fact,  in  most  cases  the  patient  \\ould  not  know  the  pessary  was  there  if  she  were 
not  told.  Inquire  also  how  much  she  has  been  relieved  from  the  previous  dis- 
comfort, for  which  the  pessary  was  introduced.  Ascertain  by  examination  if  the 
pessary  is  in  proper  position  and  if  it  holds  the  uterus  in  proper  position.  If  so 
do  not  disturl)  the  pessary  but  direct  the  patient  to  return  in  a  week.     If  the  uterus 


r 


Fig.  439.     Introducing   the    Pessarv.     The  posterior   end   depressed   and   being  pushed  past  the  cervix.      Thr 
pessary  is  shown  in  place  in  Fig.  453. 


is  out  of  position,  remove  the  pessary,  replace  the  uterus  and  introduce  anothei 
pessary,  better  adapted  to  the  case,  and  again  direct  the  patient  to  return  in  three 
days,  when  another  examination  is  to  be  made. 

When  the  pessary  is  found  satisfactory  at  the  second  and  third  visits,  it  is  to  be 
assumed  that  it  will  prove  satisfactory  right  along,  and  as  long  as  the  patient  feels 
well  she  need  not  return,  except  every  month  or  six  weeks  as  above  indiceted. 


3;Jg  GYNECOT.OGIC     TREATMENT 

This  return  at  regular  intervals  of  a  few  weeks  is  important  in  every  case  (though, 
exceptionally,  the  interval  may  be  longer)  for  three  reasons — (a)  because  the  pes- 
sary is  liable  to  accumulate  concretions  that  may  prove  irritating,  (b)  because 
long-continued  pressure  may  produce  ulceration  at  some  point  in  the  posterior 
vaginal  fornix  and  (c)  because  it  is  important  to  know  whether  the  pessary  is  doing 
the  work  it  is  used  for,  and  if  everything  is  going  as  it  should.  Injurious  pressure 
on  the  wall  is  indicated  by  a  distinct  groove  or  ridge  with  infiltration  in  the  affected 
area.  When  such  is  present,  the  pessary  should  be  left  out  for  a  few  weeks  or  a  dif- 
ferent form  used.  If  necessary  to  leave  the  pessary  out  for  a  time  and  trouble  is 
experienced  from  the  uterus  returning  to  its  malposition,  packing  in  the  knee- 
chest  posture  or  in  the  Sims  posture  may  be  employed  during  this  interval.  In 
many  cases,  however,  a  resort  to  the  knee-chest  posture  night  and  morning  is  all 
that  is  necessary. 

Douches.  The  patient  wearing  a  pessary  should  take  a  vaginal  douche  every 
day  or  every  few  days.  If  the  discharge  is  very  free  it  may  be  advisable  to  take 
two  or  three  douches  daily.  If  there  is  practically  no  discharge  two  douches 
weekly  may  be  sufficient.  Ordinarily  the  patient  is  directed  to  take  a  douche  once 
daily  or  every  other  day.  The  kind  of  douche  to  be  taken  varies  with  the  condi- 
tions present — a  large  hot  douche  or  an  astringent  douche  when  the  indications 
previously  given  for  them  are  present.  When  there  are  no  special  indications,  I 
usually  prescribe  the  bichloride  douche  or  the  aluminum  acetate  douche  (see 
Formulae). 

Knee-chest  Posture.  The  knee-chest  posture  (Fig.  469)  taken  by  the  patient 
night  and  morning,  is  very  useful  in  those  cases  in  which  the  uterus  tends  to  return 
to  its  old  position  or  in  which  the  patient  complains  of  downward  pressure  in  the 
pelvis.  It  causes  the  patient  some  inconvenience  and  is  not  necessary  when  the 
pessary  holds  the  uterus  well  up  and  entirely  relieves  the  symptoms.  But  in 
many  cases  of  damaged  pelvic  floor,  its  use  along  with  the  pessary  is  very  advan- 
tageous. 

The  activity  of  the  patient  need  not  be  cm-tailed  on  account  of  the  pessary.  The 
pessary  is  meant  to  hold  the  uterus  in  proper  position  and  restore  the  patient  to 
comparative  health,  so  that  she  can  pursue  her  usual  activities  without  disturb- 
ance. If  the  patient  cannot  pursue  her  usual  activities,  after  the  pessary  has 
been  worn  a  month  or  two,  the  pessary  has  failed  of  its  purpose,  and  some  more 
effective  method  of  treatment  is  indicated. 

As  to  coitus,  the  fact  that  a  pessary  is  being  worn  is  no  bar  to  sexual  intercourse. 
With  the  Thomas  pessary  and  the  Smith  pessary,  the  anterior  end  lies  so  high  in 
that  it  interferes  but  little,  if  at  all.  Even  with  the  Hodge  pessary,  coitus  may, 
in  some  cases,  be  accomplished  with  but  little  inconvenience.  Coitus,  however, 
causes  marked  pelvic  congestion  and  this  increases  the  liability  of  discomfort  re- 
sulting from  the  pressure  of  the  pessary.  Consequently  for  the  first  few  weeks, 
while  the  pessary  is  on  trial  so  to  speak,  coitus  had  best  be  discontinued.  Later, 
after  the  uterus  has  been  sometime  in  its  proper  position  and  the  pelvic  structures 
are  adjusted  to  the  pessary,  no  restriction  in. this  direction  is  necessary  ordinarily. 

In  some  cases,  the  replacement  of  the  uterus  and  wearing  of  the  pessary  is  car- 
ried out  principally  to  increase  the  chance  of  pregnancy,  and  in  such  cases  coitus 


WHEN  TO   I)1S(\\KI)  PESSARY  339 

is  permissible  from  the  first.  It  is  well  to  mention  this  fact  to  the  patient  or  her 
husband,  as  otherwise  it  may  be  thought  that  coitus  is  not  possible  while  the  pes- 
sary is  in  place. 

If  pregnancy  should  develop,  the  pessary  should  be  worn  just  the  same  until  the 
uterus  has  become  large  enough  to  prevent  its  sinking  back  into  the  pelvis.  The 
douche  should  then  be  taken  only  warm — not  hot,  for  a  hot  douche  may  excite 
uterine  contractions  and  lead  to  miscarriage.  Usually  along  in  the  third  or  fourth 
month  the  pessary  is  taken  out,  as  it  is  of  no  further  use  and  if  left  in  longer  it 
might  cause  irritation  and  disturbance. 

Occasionally  a  pessary  excites  pain  shortly  after  pregnancy  takes  place.  If  so, 
it  should  be  removed,  the  patient  being  directed  to  take  the  knee-chest  posture 
two  or  three  times  daily, to  keep  the  fundus  uteri  forward.  Tampons  or  tamponade 
of  the  vagina  to  keep  the  uterus  forward  is  not  advisable  in  these  cases,  as  it  might 
lead  to  miscarriage. 

When  to  Discard  the  Pessary. 

The  time  at  which  the  pessary  may  be  discarded  varies  much  in  different  cases, 
and  in  each  case  is  more  or  less  a  matter  of  trial.  A  very  good  rule  is  to  leave  out 
the  pessary  after  the  uterus  has  remained  in  position  continuously  for  three  or  four 
months.  Direct  the  patient  to  return  in  two  or  three  days.  If  the  uterus  has  re- 
turned to  its  old  backward  position,  replace  it  and  use  the  pessary  again  for  several 
months. 

If  the  uterus  maintains  its  forward  position  with  the  pessary  out,  direct  the 
patient  to  return  again  in  two  weeks.  If  then  the  uterus  is  in  proper  position  and 
the  patient  feeling  well  she  may  be  discharged,  being  directed  to  return  if  symp- 
toms should  at  any  time  reappear. 

In  some  cases  the  pessary  may  be  permanently  discontinued  in  three  or  four 
months,  but  in  more  cases  it  must  be  worn  for  six  months  or  a  year,  while  in  cer- 
tain cases,  it  must  be  worn  a  still  longer  time  or  even  indefinitely. 

If  after  the  pessary  is  removed,  the  uterus  shows  a  tendency  to  go  backward,  it 
is  well  to  have  the  patient  take  the  knee-chest  posture  occasionally  for  some  months. 

The  Inflated  Ring  Pessary. 

The  action  of  the  inflated  ring  pessary  (Fig.  460,  B)  is  principally  to  raise  the 
uterus  and  adjacent  tissues  somewhat  and  to  support  them.  It  has  no  particular 
action  in  holding  the  cervix  well  back  in  the  pelvis  nor  in  maintaining  the  uterus 
in  a  proper  forward  position .  Consequently  the  field  of  usefulness  of  this  par- 
ticular form  of  pessary  is  in  those  cases  in  which  the  uterus  cannot  be  gotten  into 
the  forward  position  or  can  not  be  maintained  there.  The  simple  supporting  of 
the  uterus,  thus  overcoming  the  slight  prolapse  which  is  present  in  most  cases  of 
retrodisplacement,  often  gives  the  patient  much  relief,  though  the  retrodisplace- 
ment  has  not  been  corrected. 

On  the  other  hand,  such  a  pessary  is  sometimes  used  by  the  physician  or  by  the 
patient  on  her  own  responsibility  (this  form  of  pessary  being  frequently  adver- 


340  GYNECOLOGIC  TREATMENT 

tised  to  the  laity),  in  cases  wliere  complete  replacement  could  be  easily  accom- 
plished. In  such  a  case,  complete  replacement  with  the  subsequent  use  of  the 
Thomas  or  Hodge  pessary  would  tend  to  effect  a  cure,  while  the  effect  of  the  in- 
flated ring  pessary  is  imperfect  and  only  temporary. 

In  the  cases  in  which  the  inflated  ring  pessary  is  useful,  some  radical  measures 
are  usually  preferable  and  the  pessary  is  simply  a  temporary  expedient  to  make 
the  patient  more  comfortable  while  she  is  getting  ready  for  operation.  Some  pa- 
tients, however,  prefer  to  wear  the  pessary  indefinitely,  even  though  it  affords  only 
partial  relief,  rather  than  submit  to  any  operative  measure. 

This  pessary  requires  a  douche  every  day  and  should  be  removed  and  cleansed 
at  least  every  week.  It  requires  more  care  to  prevent  incrustation  and  irritation. 
The  patient  can  usually  remove  and  reintroduce  the  pessary  satisfactorily  herself 
after  a  little  practice.  Just  before  introducing  it,  the  patient  should  take  the 
knee-chest  posture  for  a  few  minutes.  Then  lying  on  her  back  or  side  she  intro- 
duces the  pessary,  which  has  been  previously  cleansed  and  lubricated.  When 
coitus  is  desired,  the  pessary  may  be  taken  out  in  the  evening  and  left  out  until 
morning.  If  desired  a  loop  of  strong  string  may  be  attached  to  the  pessary  to 
facilitate  its  removal.  If  the  pessary  becomes  deflated,  it  may  be  reinflated  with 
a  hypodermic  syringe,  the  needle  being  introduced  through  the  thick  spot  designed 
for  that  purpose. 

A  pessary  of  about  this  form  is  made  of  hard  rubber  (Fig.  460,  C)  and  is  used  in 
the  same  way.  It  does  not  become  deflated  and  is  less  hkely  to  accumulate  in- 
crustation and  irritate  the  vaginal  wall.  It  is  unyielding,  however,  and  for  that 
reason  is  more  hkely  to  produce  painful  pressure  at  some  point.  Also  a  smaller 
size  must  be  used,  for  this  pessary  cannot  be  compressed,  as  the  inflated  rubber 
pessary  can,  to  pass  the  vaginal  orifice. 


Fig,  460.     A.   Flexible  Ring  Pessary.     B.   Inflated  Ring  Pessary.     C.   Hard  Rubber  Disk  Pessary. 

5.  Flexible  Ring  Pessary.  The  flexible-rubber  ring  (Fig.  460,  A)  is  sometimes 
preferable  to  the  inflated  ring,  particularly  in  cases  where  there  is  very  free  dis- 
charge. The  opening  being  larger,  the  free  discharge  escapes  easier  and  conse- 
quently there  is  less  retention  and  irritation. 

Pessaries  for  Prolapse  of  Uterus. 

The  treatment  for  prolapse  is  to  raise  the  uterus  and  maintain  the  fundus  in  a 
forward  position.  The  pessary  that  accomplishes  this  in  a  case  of  retrodisplace- 
ment  is  likewise  beneficial  in  a  case  in  which  the  prolapse  is  the  principal  feature. 


PESSARIES  FOR  PROLAPSE  OF  UTERUS 


341 


Consequently,   in  the   milder   grades  of   prolapse,  a  Thomas  or  Smith  or  Hodge 
pessary  may  be  all  that  is  necessary  to  maintain  the  uterus  in  its  proper  position. 

In  many  cases  of  prolapse,  however,  more  so  than  in  retrodisplacement,  the 
pelvic  floor  has  been  torn  so  much  that  this  form  of  pessary  will  not  stay  in  satis- 
factorily. In  such  a  case,  a  large  inflated  rubber-ring  pessary  may  be  introduced 
and  then  turned  so  it  will  not  slip  out.  This  does  not  hold  the  cervix  back  in  the 
pelvis  and  the  fundus  forward,  but  it  does  plug  the  vaginal  opening  so  the  redun- 
dant vaginal  wall  and  the  uterus  can  not  prolapse  to  the  former  extent.  If 
the  pessary  tends  to  protrude,  a  pad  over  the  genitals,  with  a  firm  T-bandage, 
may  keep  it  in  place  comfortably. 

6.  Menge  Pessary.,  A  large  thick  hard  rubber  ring, 
turned  crosswise  of  the  vaginal  opening,  will  plug 
the  opening  effectually  for  a  short  time.  But  when 
the  patient  walks  about  for  a  few  hours  the  ring  shifts 
about  until  its  edge  comes  to  the  wide  relaxed  vaginal 
opening  and  then  it    slips  out.      The  Menge  pessary 

(Fig.  461)  has  a  central 
stem  which  prevents  the 
pessary  from  turning  when 
once  in  place.  To  intro- 
duce this  pessary,  the  de- 
tachable stem  is  removed, 
(Fig.  461-B),  the  thick  ring 
introduced  and  turned 
squarely  across  the  vaginal 
opening  with  the  hole  in 
the    cross-bar    directed  ^^^'  ^^i"^- 


Fig.  461-A. 


Fig.  461.  The  Menge  Pessary.  A.  The  pessary  with  the  stem  in  place.  B.  The  pessary  with  the  stem  de- 
tached from  the  rng  portion  of  the  pessary,  preparatory  to  introduction  of  the  latter.  After  the  ring  portion 
has  been  introduced,  the  stem  is  fastened  in  place  as  shown  in  A.  The  stem  lies  in  the  vaginal  canal,  and  keeps 
the  ring  from  turning  into  any  position  that  will  allow  it  to  slip  out. 


toward  the  opening.  While  the  ring  is  held  in  this  position,  the  stem  is  fast- 
ened in  place.  The  stem  holds  the  ring  in  proper  position,  so  that  it  (the  ring) 
blocks  the  canal  and  prevents  complete  prolapse. 

This  pessary  has  proven  exceedingly  useful  in  severe  cases,  where  operation 
was  inadvisable  or  was  refused  or  where  temporary  relief  was  required  while  the 
patient  was  waiting  for  operation. 

7.  Cup  and  Belt  Pessary  (Fig.  462).  This  is  another  form  of  pessary  that  has 
given  much  relief  in  the  three  classes  of  cases  just  mentioned.  It  does  not  depend 
at  all  for  support  on  the  tissues  of  the  pelvic  floor  or  vaginal  outlet,  and  hence  is 
suitable  in  cases  where  even  the  Menge  pessary  is  expelled  or  is  unsatisfactory  on 
account  of  painful  pressure.  It  obtains  its  support  from  a  belt  about  the  abdo- 
men. There  are  various  forms,  one  of  which  may  be  preferred  by  one  patient  and 
another  by  another. 

In  many  cases  of  prolapse  in  elderly  women  with  practically  no  support  at  the 


342 


GYNECOLOGIC  TREATMENT 


A  B  CD 

Fig.  462.      A.  Cup  and  Belt  Pessary.      B,  C,  D.   Different  of  Cups  that  may  be  used. 


Fig.  463.  Gehruiig's  Ante- 
version  Pessary,  which  is  very 
useful  in  Cystocele.  (Hirst — 
Diseases  of  Women.) 

pelvis  roomy  and  the  cervix 
so  small  that  it  does  not 
stay  in  the  cup  well. 

Ordinarily,  however,  the 
cup  is  preferable,  as  it  holds 
the  cervix  well  back  and 
up  in  the  pelvis  and  thus 
keeps  the  vaginal  wall'  on 
the  stretch  without  making 
uncomfortable  pressure  on 
adjacent  organs. 

Pessaries  for  Cystocele. 

In  many  cases  of  cysto- 
cele much  relief  may  be 
given  by  the  use  of  one  of 


pelvic  outlet,  this  pessary  has  given  great 
relief,  even  permitting  the  patient  to  work 
hard  with  comparatively  little  discomfort. 
Of  course  this  is  only  a  makeshift,  giving 
temporary  relief,  and  curative  operative 
measures  are  preferable  in  suitable  cases. 
But  some  of  these  women  are  not  in  fit 
physical  condition  for  operation  and  others 
refuse  operation,  preferring  to  get  along. 
with  a  fairly  satisfactory  pessary. 

A  modification  of  the  cup  and  belt  pes- 
sary is  made  by  substituting  a  ball  for  the 
cup.  This  form  is  more  useful  than  the 
cup  in  some  cases,  particularly  when  the 
vaginal  walls  are  very  redundant  and  the 


Fig.  464,     Introdlioing  the  Gehrung  Pessary, 
o/  Womtn.) 


{Rmi— Diseases 


PESSARIES  FOR  CYSTOCELE 


343 


the  forms  of  pessary  already  described,  the  maintaining  of  the  cervix  well  upward 
and  backward  doing  away  temporarily  with  the  cystocele.  In  other  cases  the 
cystocele  is  the  principal  feature  and  gives  trouble  in  spite  of  tlu;  maintenance 
of  the  uterus  in  approximately  correct  position.     In  such  cases,  operation  as  a 


a 


Fig.  465.  Skene's  Cystocele  Pessary  The  first  figure  Ca)  shows  the  outline  of  the 
pessary,  and  the  second  figure  shows  the  pessary  in  place  supporting  the  anterior  vaginal 
wall.      (Ashton — Practice  of  Gynecology.) 


rule  is  indicated.  In  cases  where  operation  is  not  advisable  or  where  tempo- 
rary relief  is  desired  while  the  patient  is  waiting  for  operation,  one  of  the  follow- 
ing pessaries  may  prove  useful. 

8.  Qehrung's  Anteversion  Pessary.  This  pessary,  devised 
by  Dr.  E.  C.  Gehrung,  of  St.  Louis,  is  the  most  effective 
form  yet  presented  for  the  treatment  of  cystocele.  Fig. 
463  shows  the  shape  of  the  pessary  and  also  the  relation 
it  bears  to  the  uterus  when  in  place.  The  method  of  its 
introduction  is  shown  in  Fig.  464. 

9.  Skene's  Cystocele  Pessary.  This  has  been  extensively 
used  for  cystocele  and  is  very  satisfactory  in  many  cases. 
The  form  of  the  pessary  and  also  its  action  when  in 
place,  are  shown  in  Fig.  465. 

10.  Globe  Pessary  (Fig.  466).  This  puts  the  relaxed 
vaginal  walls  on  the  stretch  and  prevents  prolapse  of  the 
bladder,  but  is  likely  to  make  uncomfortable  pressure  on 

surrounding  structures.  In  cases  where  it  is  satisfactory  except  that  it  slips 
out,  it  may  be  held  in  place  by  a  firm  pad  and  T-bandage. 


Fig.  466.  Globe  Pessarj', 
with  cord  attached  so  that 
the  patient  may  remove  it 
as  necessarj'.  (Hirst — 
Diseases  of  Women). 


Other  Kinds  of  Pessaries. 

There  are  many  other  forms  of  pessaries  in  use,  but  to  mention  all  of  these  vari- 
ous kinds  would  only  cause  confusion.     It  is  better  to  learn  to  use  a  few  well  than 


344  GYNECOLOGIC  TREATMENT 

to  be  tr3T.iig  all  of  the  fanciful  shapes  devised.  The  styles  already  mentioned,  if 
intelligently  used,  \^-ill  answer  the  purpose  in  practically  all  cases  in  which  the  use 
of  a  pessary  is  the  preferable  method  of  treatment. 

SUBMUCOUS   INJECTION    OF    PARAFFIN. 

The  submucous  injection  of  paraffin  has  been  successfully  emploj^ed  in  some 
cases  of  incontinence  of  urine  and  also  in  certain  cases  of  prolapse  of  the  uterus  or 
vagina.  However,  it  is  held  by  Stolz,  who  speaks  from  considerable  experimental 
and  clinical  experience,  that  plastic  operation  are  far  preferable.  In  cases  of  pro- 
lapse of  the  uterus  or  vaginal  wall  in  which  operation  is  not  advisable,  pessaries 
are  as  a  rule  preferable  to  paraffin  injections.  The  use  of  the  latter  is  in  a  measure 
experimental  and  is  accompanied  ^^ith  danger  of  embolism  and  should  be  used 
only  after  careful  study  and  under  special  precautions. 

LOCAL  BLOOD-LETTING. 

In  cases  of  chronic  inflammation  and  congestion  of  the  cervix,  particularly 
where  there  is  much  cystic  change,  some  benefit  may  be  derived  from  multiple 
punctures  of  the  cervix  with  a  bistory-point.  This  causes  free  bleeding  from  the 
chronically  congested  cervix,  and  at  the  same  time  opens  and  evacuates  man}' 
small  cysts.  The  drainage  of  blood  and  serum  from  the  cervix  may  be  prolonged 
by  the  use  of  a  warm  (not  hot)  douche  within  an  hour  or  two  afterward.  The 
punctures  into  the  cervix  for  an  eighth  to  a  quarter  of  an  inch  cause  no  particular 
pain.  The  adjacent  vaginal  wall,  however,  is  sensitive  to  puncture  or  grasping 
with  tenactilum-forceps,  and  hence  should  be  carefully  avoided. 

Before  making  multiple  punctures  in  the  cervix,  be  careful  to  determine  exactly 
the  cause  of  the  chronic  congestion.  It  may  be  due  to  pregnancy,  which  would  of 
course  contra-indicate  multiple  puncture. 

THE  CURET. 

The  sharp  curet  is  used,  in  the  treatment  of  affections  of  the  vulva  and  vagina 
and  cervix,  for  the  following  purposes. 

To  remove  infected  or  otherwise  diseased  tissue. 
To  stimulate  healthy  granulation. 
To  secure  specimens  for  microscopic  examination. 
Its  principal  use  is  in  the  treatment  and  diagnosis  of  chronic  ulcers.     The  occa- 
sional curetting  away  of  the  unhealthy  granulations  of  an  indolent  ulcer,  does  much 
to  assist  in  its  healing  and  also  furnishes  tissue  for  microscopic  examination  in 
doubtful  cases. 

Occasionally  also  a  thorough  curetting  of  the  interior  of  a  chronically  inflamed 
cervix  v.'ill  be  beneficial. 

Before  using  the  curet,  the  surfaces  should  be  anesthetized  partially,  l)v  a  pledget 
of  cotton  soaked  in  a  20  per  cent,  solution  cocaine  being  laid  on  the  surface  for  five 
minutes. 


THE  X-KAV  TKEATMENT  34?. 


THE  CAUTERY. 


The  Paquelin  thermo-caiitery  or  the  electric  cautery  is  useful,  on  the  surfaces 
under  consideration,  for  the  following  purposes: 

To  destro}"  the  virus  in  a  chancroid. 

To  destroy  unhealthy  granulations  or  infected  tissue. 

To  excise  small  growths  (condylomata,  etc.). 

To  destro}"  retention  cj'sts  in  the  cervix. 
Before  using  the  cautery,  the  parts  are  usually  anesthetized  by  the  local  applica- 
tion of  a  20  per  cent,  cocaine  solution  on  a  pledget  of  cotton  or,  in  the  case  of  a 
growth,  by  the  hypodermic  injection  of  a  §  per  cent,  cocaine  solution  under  the 
base. 

ELECTRICITY. 

The  uses  of  electricity  (galvanic  current,  faradic  current),  as  applied  to  the  ex- 
ternal genitals  and  vagina  and  cervix,  are  principally  two — first,  as  the  electric 
cautery  for  destroying  diseased  tissue  or  excising  growths  and,  second,  as  a  seda- 
tive for  relieving  persistent  itching  or  pain.  The  details  of  the  application  of  elec- 
tricity in  gynecological  work  are  given  further  along,  under  Intra-uterine 
Treatment. 

X-RAY  TREATMENT. 

The  X-Ray  treatment  has  not  fulfilled  expectation  as  to  curative  effects  in 
malignant  disease. 

■fhe  present  status  of  the  subject  is  w^ell  summed  up  by  Dr.  Wm.  B.  Coley  of  New 
York,  who  reports  on  the  results  of  his  experience  with  this  agent  in  the  treatment  of 
167  cases  of  malignant  disease,  and  reviews  the  reports  of  other  series  of  cases.  He 
states  (Annals  of  Surgery,  August,  1906)  that  the  results  of  X-Ray  treatment  of 
malignant  tumors  up  to  the  present  time  have  proven  as  follows: — • 

''1.  That  the  X-Ray  exerts  a  powerful  influence  upon  cancer  cells  of  all  vari- 
eties, but  most  marked  in  cases  of  cutaneous  cancer. 

2.  In  some  cases,  chiefly  in  superficial  epithelioma,  the  entire  tumor  may  dis- 
appear, probably  by  reason  of  fatty  degeneration  of  the  tumor  cells,  with  subse- 
quent absorption. 

3.  In  a  much  smaller  number  of  cases  of  deep-seated  tumors,  chieflj''  cancer  of 
the  breast  and  glandular  sarcoma,  tumors  have  disappeared  under  prolonged 
X-Ray  treatment.  In  nearly  every  one  of  these  cases,  however,  that  has  been 
traced  to  final  results,  there  has  been  a  local  or  general  return  of  the  disease  within 
a  few  months  to  two  years. 

4.  In  view  of  this  practically  constant  tendency  to  early  recurrence  and,  fur- 
thermore, in  the  absence  of  any  reported  cases  well  beyond  three  years,  the  method 
should  never  be  used  except  in  inoperable  cases,  or  as  a  prophylactic  after  opera- 
tion, as  a  possible,  though  not  yet  proven,  means  of  avoiding  recurrence. 

5.  The  use  of  the  X-Ray  as  a  preoperative  measure  in  other  than  cutaneous 
cancer  is  contradicted,  (l)because  that  agent  has  not  yet  proven  to  be  curative 


346  GYNECOLOGIC  TREATMENT 

and  (2)  because  of  serious  risks  of  an.  extension  of  the  disease  to  inaccessible  glands 
or  to  other  regions  by  metastases  during  the  period  required  for  a  trial." 

Even  in  the  superficial  malignant  tumors,  it  is  safer  to.  excise  the  growth  and 
then  use  the  X-Ray,  rather  than  to  trust  entirely  to  the  latter. 

In  certain  intractable  non=malignant  affections  the  X-Ray  has  produced  most 
satisfactory  results. 

In  severe  pruritus  vulvae  presisting  in  spite  of  many  other  measures,  this 
treatment  has  affected  a  cure.  In  tuberculosis  of  the  vulva,  in  ulcus  rodens  and  in 
chronic  eczema  it  has  proven  exceedingly  beneficial.  In  any  chronic  ulceration 
or  infiltration  that  resists  other  measures,  this  treatment  may  be  given  a  thor- 
ough trial  with  good  prospect  of  relief.  It  must,  of  course,  be  applied  in  the 
proper  way,  according  to  the  indications  in  that  case  and  by  a  physician  who  has 
made  a  real  study  of  the  subject.  A  large  proportion  of  the  so-called  X-Ray  In- 
stitutes and  Laboratories,  so  generously  advertised  in  the  newspapers,  are  simply 
X-Ray  fakes. 

THE  FINSEN  LIGHT. 

Much  has  been  claimed  for  the  Finsen  Light  and  allied  ray-treatment  in  gyne- 
cological work,  and  many  cases  indicating  beneficial  result ;  have  been  reported. 
But  most  of  the  reports  that  have  come  to  my  notice  have  seemed  to  be  the 
result  of  enthusiastic  seeking  for  good  results  rather  than  critical  analysis  of  cases 
and  effects. 

In  superficial  tuberculosis  and  in  other  non-malignant  chronic  ulcerations,  it 
may  be  used  with  great  benefit.  But  further  than  that  its  use  is  still  in  the 
stage  of  experimentation.  No  time  should  be  wasted  with  it  in  operable  cases 
of  malignant  disease. 

RADIUM. 

The  employment  of  radio-active  substances  in  the  treatment  of  various  forms 
of  ulceration  about  the  genitals,  is  still  experimental.  Some  clinical  results  have 
been  reported,  but  not  in  a  way  that  gives  much  confidence  as  to  lasting  benefit. 
While  it  is  advisable  to  continue  experimentation  to  determine  the  therapeutic 
value  of  radio-activity,  it  should  not  displace  the  recognized  and  well-tried  thera- 
peutic measures.  The  so-called  ''wonderful  cures"  of  serious  diseases  by  radium, 
so  widely  heralded  in  the  daily  press,  may,  as  far  as  any  real  evidence  that  has 
come  to  my  notice,  be  set  down  as  the  wonderful  fancies  of  an  enthusiast  or  the 
wonderful  lies  of  a  faker. 


INTRA-UTERINE  TREATMENT. 

MEDICATED  APPLICATIONS  WITHIN  THE  UTERUS. 
Effects,  Good  and  Bad. 

What  good  can  intra-uterine  applications  do? 

They  may  exercise  uu  antiseptic,  astringent  or  anesthetic  efTect. 
They  may  destroy  diseased  tissue. 
They  may  exercise  a  hygroscopic  effect. 


EFFECTS   OF  INTRA-UTERINE  APPLICATIONS  ;^47 

1.  They  may  exercise  an  antiseptic  or  astringent  or  anesthetic  effect,  limited  to 
the  surface  to  which  they  arc  applied.  Ovviiif;-  to  peculiarities  in  liie  luiturc  and 
situation  of  the  endometrium,  an  intra-utcrine  application  of  an  antiseptic  does 
not  ordinarily  have  much  influence  in  checkini-;  the  activity  of  bacteria  that  hav(^ 
gained  a  foothold  there.  The  three  most  important  influences  limiting  l)acterial 
penetration  into  the  uterine  wall  are  (a)  an  intact  epithelial  surface,  (b)  the  bac- 
teriacidal  influence  of  leucocytes  and  blood  serum  and  lymph,  and  (c)  the  absence 
of  irri  ation  (toxic,  chemical,  mechanical)  within  the  cavity. 

In  a  patient  with  bacterial  invasion  of  the  endometrium,  after  the  uterus  has 
been  cleared  of  placental  remnants  and  good  drainage  secured  (removal  of  toxic, 
chemical  and  mechanical  irritation)  the  issue  depends  almost  wholly  on  the  bac- 
teriacidal  and  antitoxic  influence  of  the  leucocytes,  blood  serum  and  lymph.  The 
efficacy  of  any  therapeutic  measure  employed  must  l)e  judged  largely  by  its  in- 
fluence on  this  battle  beneath  the  surface,  rather  than  by  any  superficial  effect. 
The  beneficial  effect  of  killing  a  few  bacteria  upon  the  surface  is  more  than  over- 
balanced by  the  local  disturbance  whicli  the  application  occasions.  It  adds  irri- 
tation to  the  already  great  irritation  from  the  bacteria  and  their  products,  and  it 
opens  up  new  avenues  for  invasion,  by  abrasion  of  the  protecting  epithelial  cover- 
ing. In  chronic  cases,  the  bad  effect  of  such  applications  is  not  great,  because 
nature  has  the  process  well  limited,  but  occasionally,  even  in  these  cases,  there 
will  be  considerable  disturbance  following  the  application,  due  to  immediate  ex- 
tension of  the  infection  deeper  into  the  uterine  wall  or  into  the  tubes  or  para- 
metrium. In  the  acute  and  subacute  stages  of  bacterial  invasion  of  the  uterus 
(puerperal  or  nonpuerperal)  an  intra-uterine  application  very  frequently  causes 
an  aggravation  of  the  trouble,  as  evidenced  by  a  chill  and  a  sharp  rise  of  temper- 
ature within  a  few  hours. 

It  may,  I  think,  be  stated  as  a  general  proposition,  that  intra-uterine  applica- 
tions for  antiseptic  effect,  in  the  acute,  subacute  or  chronic  stages  of  l^acterial  in- 
vasion, do  more  harm  than  good.  The  harm  is  due,  not  to  the  presence  of  the  anti- 
septic, but  to  the  abrasions  of  the  endometrium  incident  to  the  application. 

If  the  antiseptic  effect  could  be  secured  without  these  minute  traumatisms, 
which  are  incident  to  the  introduction  of  any  instrument  within  tlie  cavity,  the 
applications  might  be  beneficial,  provided  they  are  made  in  an  aseptic  way.  There 
is  one  method  that  promises  something  along  this  line,  namely,  the  use  of  uterine 
suppositories,  of  such  consistency  that  they  can  not  abrade  the  surface  of  the 
endometrium. 

The  use  of  an  astringent  intra-uterine  application  is  advisable  in  certain  excep- 
tional cases  of  persistent  bleeding  or  free  discharge  from  the  endcmetiium,  not 
dependent  on  l^acterial  invasion  or  a  new  growth.  There  are  many  cases  of  l^leed- 
ing  (especially  menorrhagia)  due  simply  to  chronic  congestion  and  hyperplasia  of 
endometrium.  It  is  principally  in  those  dependent  on  subinvolution  and  which 
have  not  been  relieved  by  internal  treatment  (laxatives,  general  tonics,  uterine 
astringents)  and  hot  vaginal  irrigation  and  other  measures  directed  towards  dimin- 
ishing the  pelvic  atony  and  congestion,  that  local  astringent  applications  are  of 
service. 


348  GYNECOLOGIC  TREATMENT 

In  most  of  these  persistent  cases  it  is  preferable  to  remove  the  thickened  en- 
dometrium with  the  curet.  But  in  some  cases  the  symptoms  are  hardly  sufficient 
to  demand  curetment,  or  the  patient  objects  to  it.  In  such  a  case  a  few  astringent 
applications  to  the  endometrium;  made  under  proper  precautions,  may  do  much 
good  without  doing  damage.  A  few  abrasions  of  the  epithelium  by  an  aseptic 
application  in  such  a  case,  are  of  less  consequence  than  when  made  in  an  infected 
cavity  where  there  are  bacteria  ready  to  enter  the  abrasions.  Also  the  chemical 
and  mechanical  irritation  is  better  borne  because  there  is  no  deep-seated  bacterial 
activity.  Occasionally  such  an  application  is  indicated  in  the  simple  hyperplastic 
endometritis  in  a  virgin.  But  the  discomforts  and  difficulties  of  a  satisfactory 
intra-uterine  application  in  the  A'irgin  are  such  that  when  intra-uterine  treatment 
is  necessary,  thorough  dilatation  under  anesthesia  and  curetment  is  usually  the 
preferable  method. 

In  infective  endometritis,  the  application  will  probably  do  more  harm  than  good, 
except  in  those  old  cases  in  which  the  bacteria  are  dead  or  so  attenuated  that  the 
condition  is  practically  one  of  simple  endometritis. 

In  bleeding  due  to  fibroids  or  malignant  disease,  astringent  applications  exer- 
cise no  influence  over  the  course  of  the  disease,  and  may  cause  infection  and  thus 
increase  the  danger  of  the  necessary  operation.  For  temporary  control  of  bleed- 
ing while  waiting  for  operation,  general  measures  and  internal  medication  and 
firm  vaginal  packing  will  nearly  alwaj^s  suffice.  For  the  inoperable  cases,  other 
methods  more  effective  are  at  our  disposal. 

An  anesthetic  application,  such  as  cocaine  or  orthoform,  is  useful  when  applied 
about  a  sensitive  internal  os,  preceding  dilatation  of  the  same.  The  pain  is  usually 
considerably  diminished.  Applications  of  anesthetic  substances  to  the  endo- 
metrium proper  are  of  httle  benefit  and  present  the  dangers  common  to  all  intra- 
uterine applications. 

2.  They  may  destroy  diseased  tissues.  This  will  be  spoken  of  under  cauteriza- 
tion. 

3.  They  may  exercise  a  hygroscopic  effect.  This  effect,  secured  by  the  small 
amount  of  hygroscopic  material  retained  in  the  uterus,  is  so  slight  that  intra- 
uterine applications  for  this  purpose  are  not  advisable. 

What  harm  can  intra-uterine  applications  do? 

Same  that  vaginal  applications  may,  and  also: 

May  carry  infection  into  the  uterus. 

May  increase  bacterial  disturbance  already  in  the  uterus. 

1.  They  may  cause  the  same  harmful  effects  that  vaginal  applications  maj'. 
That  is,  they  may  (a)  cause  patient  to  come  to  office  when  she  should  be  resting 
at  home,  (b)  cause  postponement  of  effective  treatment  until  the  disease  is  past 
cure  and  (cj  convert  a  neurasthenic  or  hysteric  individual  into  a  confirmed  invalid 
by  fixing  attention  on  some  trivial  local  disturbance. 

2.  They  may  carry  infection  into  the  uterus  and  change  some  simple  disturb- 
ance into  a  very  serious  one.  This  has  happened  many  times  and  constitutes  One 
of  the  most  serious  objections  to  intra-uterine  applications.  By  taking  proper 
care  of  the  cervical  canal  with  an  antiseptic,  infection  can  usually  be  avoided. 


HOW  TO  MAKE  INTRA-UTERINE  API'IJCATIONS  34v 

But  even  with  this  care,  infection  ma}'  he  carried  in  from  an  apparently  lieahhy 
cervix.  It  is  an  ever-present  (hmger  and  must  be  over-hahinccd  hy  tlie  probable 
benefit  in  the  particular  case,  before  an  intra-uterine  application  is  advisable. 

3.  They  may  increase  a  bacterial  disturbance  already  in  the  uterus,  as  previ- 
ously explained. 


Methods  of  Intra-Uterine  Application. 

1.  With  Cotton-wrapped  Applicator.  An  intra-uterine  application  is  made  liy 
wrapping,  with  disinfected  fingers,  a  small  amount  of  absorbent  cotton  about  the 
end  of  an  applicator  (Fig.  467,  b),  saturating  the  cotton  with  the  desired  medicine 
and  then  carefully  introducing  it  through  the  cleansed  and  dilated  cervical  canal 
into  the  cavity  of  the  corpus  uteri.  In  making  an  intra-uterine  application,  the 
same  antiseptic  care  must  be  observed  as  in  sounding  the  uterus. 

It  is  well  to  prepare  a  number  of  cotton-wrapped  aluminum  applicators  (Fig. 
467,  c)  and  have  them  in  sterile  wide-mouthed  bottles  (Fig.  467),  some  dry  steri- 
lized and  others  in  some  of  the  solutions  frequently  used.  Then  you  can  be  cer- 
tain that  the  cotton  on  your  applicators  is  sterile,  as  it  is  very  likely  not  to  be  if 
it  is  twisted  on  hurriedly  during  the  office  treatment,  for  it  is  difficult  to  steri 
lize  the  fingers  and  keep  them  sterile. 

2.  With  Gauze.  Another  method  and  a  very  effective  one  for  bringing  medi- 
cine in  contact  with  the  endometrium,  is  to  soak  the  end  of  a  small  strip  of  anti- 
septic gauze  in  the  medicine  and  carry  it  into  the  uterus  and  leave  it  there.  The 
remaining  part  of  the  gauze  is  packed  against  the  cervix  to  hold  the  uterine  portion 
in  place.  The  other  end  of  the  gauze  is  brought  near  the  vaginal  outlet  so  that 
the  patient  may  remove  it  after  several  hours. 

3.  Slippery =Elm  Applicator.  A  method  somewhat  similar  to  the  last  mentioned, 
is  the  use  of  a  small  slippery-elm  tent,  sterilized  and  dipped  in  the  medicine  and 
carried  into  the  cavity  and  left  there.  A  string  is  attached  by  which  the  patient 
can  remove  it  as  directed.  My  colleague.  Dr.  Frank  A.  Glasgow,  thinks  very 
highly  of  this  device,  and  for  many  years  has  used  it  almost  exclusively  in  intra- 
uterine applications. 

4.  Uterine  Suppositories,  or  soluble  uterine  bougies,  furnish  another  method  of 
applying  medicine  to  the  endometrium.  Protargol  and  iodoform  are  the  medi- 
cines usually  incorporated  in  them. 

It  is  possible  that  there  will  be  worked  out  along  this  line,  a  method  of  making 
effective  antiseptic  and  astringent  applications  without  mechanical  disturbance 
of  the  endometrium.  If  so  this  might  prove  of  decided  help  in  the  treatment  of 
bacterial  invasion,  in  both  the  acute  and  chronic  stages.  It  seems  to  me  that  more 
will  be  accomplished  in  this  direction  by  using  the  penetrating  antiseptics,  such 
as  collargolum  or  Crede's  ointment,  than  by  the  use  of  the  surface  antiseptics 
usually  employed. 

The  injection  of  medicines  into  the  uterine  cavity  by  means  of  the  intra-uterine 
syringe,  I  can  not  recommend.     Its  danger  outweighs  its  advantages. 


850 


GYNECOLOGIC  TREATMENT 


For  What  Effects  Indicated. 

As  pre^dously  explained,  the  only  intra-uterine  applications  advisable  ordinarily 
are  those  for  an  astringent  or  anesthetic  effect  in  the  non-infected  uterus,  anci 
even  these  only  in  exceptional  cases  and  for  a  short  time. 


Fig.  467.  Applicators  for  Intrauterine  Treatment,  a.  The  ordinary 
handled  applicator,  b.  The  same  wrapped  with  cotton,  preparatory  to 
dipping  it  into  the  medit-ine  to  be  applied  withiin  the  uterus,  c.  Plain 
aluminum  wire  applicator,  nine  inches  long.  d.  The  same  wrapped  with 
cotton.  The  jar  contains  prepared  applicators  like  (d),  and  is  ready  to 
receive  the  solution  in  which  they  are  to  be  kept. 


MEbUUNES  FOR  INTRA-U TEUINE  APlM,lCATION  351 

Long  continued  intra-uterine  applications  do  little  or  no  good  and  may  do  much 
harm.  They  may  cause  the  inflammation  to  extend  deeper  into  the  uterine  wall 
or  into  the  parametrium  or  into  the  Fallopian  tubes.  If  no  decided  l)eneficial 
effect  is  apparent  from  a  few  applications,  made  at  intervals  of  several  days, 
they  should  be  discontinued  and  more  effective  measures  employed. 

Medicines  Used  for  Intrauterine  Application. 

The  medicines  used  for  astringent  effect  are: — 
Protargol,  5  to  10%. 
Formol,  20  to  40%. 

Iodized  Phenol  (Tinct.  iodine  and  carbolic  acid,  equal  parts) 
Carbolic  Acid,  10  to  95%. 
Copper  Sulphate,  10%. 
Adrenalin  Chloride,  1-1000. 

The  medicines  used  for  anesthetic  effect  are: — 

Cocaine  Hydrochlarate,  10  to  20%. 

Orthoform. 

Chloretone. 
Local  anesthetic  appHcations  are  seldom  used  within  the  uterus.  About  the 
only  indication  is  for  the  diminution  of  pain  due  to  dilatation  of  the  cervical 
canal.  A  few  minutes  before  the  dilatation  an  application  of  the  desired  local 
anesthetic  is  made  along  the  canal,  especially  about  the  internal  os  which  is  the 
most  sensitive  part. 

HOT  WATER  IRRIGATION. 

Intra-uterine  irrigation  is  employed  in  the  treatment  of  acute  endometritis,  par- 
ticularly that  form  caused  by  infection  following  labor  or  abortion.  With  the 
same  antiseptic  precautions  as  for  sounding  the  uterus,  the  double  current  irrigat- 
ing tube  is  introduced  into  the  uterine  cavity  and  a  large  amount  (half  a  gallon  to 
a  gallon)  of  hot  sterile  water,  or  normal  salt  solution,  is  allowed  to  pass  slowly 
through  the  uterus.  This  removes  mechanically  a  large  amount  of  the  infective 
material  and  the  effect  of  the  hot  water  is  beneficial  in  tending  to  allay  the  inflam- 
mation. In  some  cases  of  puerperal  sepsis,  this  irrigation  is  sufficient  to  check  the 
trouble,  but  in  other  cases  there  remains  infected  material  that  must  be  removed 
by  the  finger  or  curet.  One  thorough  irrigation  is  usually  all  that  is  advisable, 
provided  the  uterine  cavity  drains  well.  Of  course  if  there  is  distinct  retention  ol 
pus  within  the  uterus  then  the  cervix  must  be  opened  and  the  pus  washed  out  as 
often  as  such  retention  occurs.  Intra-uterine  irrigation  has  been  used  also  in  the 
treatment  of  acute  gonorrhoeal  endometritis  but  the  effect  was  not  such  as  to 
encourage  its  use. 

Prolonged  hot  intra-uterine  irrigation  has  been  used  also  in  the  treatment  of 
chronic  endometritis  with  decided  benefit  in  some  cases.  In  the  uterus  not  rec- 
cently  pregnant,  the  cervix  may  require  considerable  dilatation  before  it  will  admit 
the  irrigating  tube.  The  required  dilatation  can  usually  be  easily  accomplished 
by  using  the  graduated  cervical  dilators,  of  hard  rubber  or  metal. 


352  GYNECOLOGIC  TREATMEXT 

In  addition  to  the  dangers  incident  to  all  intra-uterine  manipulations  (irrita- 
tion, abrasions,  infection),  irrigation  presents  the  danger  of  fluid  extending  into 
the  tubes  and  out  into  the  peritoneal  cavity.  To  avoid  this,  the  return-flow  must  be 
unobstructed  and  the  irrigating  receptacle  not  more  than  two  feet  above  the  uterus. 
In  puerperal  infection,  after  the  uterus  is  thoroughly  cleansed  of  placental  rem- 
nants and  infected  clots,  and  free  drainage  is  secured,  the  less  intra-uterine  inter- 
ference for  irrigation  or  other  cause,  the  better  as  a  rule. 

In  chronic  endometritis  the  treatment  by  intra-uterine  hot  water  irrigation  is 
still  on  trial.  The  indications  so  far  are  that  in  the  cases  really  requiring  intra- 
uterine treatment,  more  effective  methods  are  preferable. 

CURETMENT. 

The  use  of  the  curet  within  the  uterus  in  office  work  is  very  limited.  It  is  used 
nearly  altogether  for  diagnostic  purposes,  though  occasionally  in  a  case  of  hyper- 
trophic endometritis  with  a  wide  cervical  canal,  it  may  be  advisable  to  curet  suf- 
ficiently to  remove  a  large  part  of  the  endometrium  and  secure  a  therapeutic  effect. 

The  precautions  are  the  same  as  for  sounding  the  uterus. 

Usually  the   Sims  posture  T\ill  be  found  most  convenient. 

Regular  curetment  under  anesthesia,  properly  carried  out  in  suitable  cases,  is 
one  of  the  most  beneficial  of  gj^necologic  therapeutic  measures.  By  it,  the  chron- 
ically diseased  endometrium  may  be  largely  removed.  This  stops  the  bleeding 
and  leaves  the  surface  in  a  good  condition  for  the  rapid  regeneration  of  a  compar- 
atively healthy  endometrium  (Figs.  589,  590,  591).  In  practically  all  cases  of 
chronic  uterine  bleeding  or  free  discharge,  in  which  the  trouble  is  not  amenable  to 
a  few  intra-uterine  applications,  regular  curetment  under  anesthesia  is  indicated 
both  for  therapeutic  effect  and  for  diagnosis.  Regular  curetment  is  considered 
in  detail  in  chapter  vi,  under  Chronic  Endometritis. 

CAUTERIZATION  OF  ENDOMETRIUM. 

Destruction  of  the  endometrium  b}-  cauterization  was  formerly  much  practiced 
in  cases  of  persistent  bleeding  or  discharge.  It  has  been  found,  however,  that  in 
all  but  exceptional  cases,  a  curetment  is  more  effective  and  leaves  the  uterus  in 
better  condition  for  the  regeneration  of  a  healthy  endometrium,  as  explained  and 
illustrated  in  chapter  vi. 

In  cases  where  curetment  can  not  be  carried  out  or  is  not  effective,  cauteriza- 
tion may  be  employed.  For  accomplishing  this  there  are  three  methods — by 
chemicals,  by  steam,  by  electricity. 

Cauterization  of  Endometrium  by  Chemicals.  Chloride  of  zinc  was  formerly 
much  used,  as  was  also  nitric  acid.  The  effect  of  these  strong  deeply  cauterizing 
agents  in  many  cases  was  to  destroy  the  endometrium  beyond  the  possibility  of 
satisfactory  regeneration  (see  Fig.  592),  the  interior  of  the  uterus  being  in  many 
cases  converted  into  a  mass  of  scar  tissue. 

Carbolic  acid  (95%)  does  very  well  as  a  superficial  cauterant,  but  it  does  not 
cauterize  deeply  enough  to  approach  in  effectiveness  curetment  as  a  means  of  re- 


CAUTERIZATION.     ELECTRICITY  353 

moving  a  diseased  and  bleeding  endometrium.  When  a  superficial  effect  only  is 
required,  it  does  very  well,  applied  as  an  ordinary  medicated  iutra-utei-inc  aj)pli- 
cation.  Care  is  necessary,  however,  to  avoid  cauterizing  the  vaginal  wall  and  also 
to  avoid  concentrating  the  effect  in  the  narrow  part  of  the  cervical  caiud,  near  the 
internal  os,  with  almost  no  effect  above.  This  is  avoided  by  having  the  cervical 
canal  well  dilated,  so  the  charged  applicator  will  pass  in  easily. 

The  stronger  formol  solutions  (30%  to  50%)  have  a  superficial  cauterizing  effect. 

Cauterization  of  Endometrium  by  Steam.  By  means  of  the  Pincus  apparatus, 
the  intra-uterine  application  of  steam  has  been  made  practical.  A  thorough 
curetment  (under  anesthesia)  precedes  the  application  of  steam.  Then  the  steam, 
under  the  control  of  the  Pincus  apparatus,  is  applied  for  a  few  seconds.  This  cau- 
terizes the  interior  of  the  uterus,  and  stops  metrorrhagia  in  some  cases  where  other 
measures,  including  repeated  curetment,  have  failed. 

It  is  a  dangerous  measure,  however,  and  is  not  suitable  for  general  u.se.  It  has 
caused  deaths,  also  atresia  of  the  uterine  canal  necessitating  suVjsequent  hysterec- 
tomy. It  is  not  to  be  used  as  a  substitute  for  curetment  or  other  less  dangerous 
measures,  but  is  to  be  employed  only  as  a  substitute  for  hysterectomy  in  cases  of 
persistent  metrorrhagia  due  to  a  non-malignant  pathological  process  in  the  en- 
dometrium. 

Cauterization  of  Endometrium  by  Electricity.  This  is  often  very  effective  where 
a  mild  cauterizing  effect  is  desired,  to  check  a  persistent  menorrhagia  or  metror- 
rhagia not  dependent  on  malignant  disease  nor  active  infection.  The  treatments 
may  be  given  in  the  office  easily  and  with  but  little  d  scomfort  to  the  patient  in 
suitable  cases.  Where  curetment  is  not  required  for  diagnosis,  electricity  may  in 
some  cases  be  uced  as  an  effective  substitute  for  it,  and  anesthesia  thus  avoided. 

The  details  of  the  application  of  electricity  in  this  and  other  cases  are  given  below. 

ELECTRICITY. 

Electricity  is  a  useful  method  of  treatment  which  has  fallen  into  disrepute  be- 
cause too  much  was  expected  of  it  and  claimed  for  it.  The  manner  of  its  presen- 
tation was  confusing  and,  with  the  small  results, discouraging.  It  was  put  forward 
as  a  wonderful  cure-all,  with  a  mysterious  source,  action  and  effect.  Its  clinical 
use  and  understanding  supposedly  necessitated  the  perusal  of  volumes  of  explana- 
tions— sensible  and  absurd,  chemical,  physical,  physiological  and  psychical.  By 
the  time  the  reader  had  made  good  progress  into  the  explanations,  he  was  so  be- 
wildered and  befuddled  that  the  only  tangible  conclusion  he  could  reach  was  that 
it  was  a  wonderful  remedy  and  must  certainly  produce  wonderful  results  for  what- 
ever used. 

When  the  actual  clinical  results  were  viewed  in  the  same  way  that  results  from 
therapeutic  measures  without  mysterious  trimmings  were  vie.i\'e(l,  it  was  found 
that  many  of  the  strongest  claims  were  without  foundation  in  fact. 

Because  of  this  conspicuous  failure  in  certain  particulars,  some  have  been  led  to 
the  mistaken  idea  that  it  is  a  total  failure  as  a  therapeutic  agent.  Less  of  mystery 
and  finely-spun  theorizing  and  more  of  common  sense  and  critical  testing  of  results 


354  GYNECOLOGIC  TREATMENT 

by  reliable  methods,  have  shown  that  its  usefulness  in  strictly  gynecologj^ai  ofibes 
is  very  limited,  but  within  those  hmits  it  is  effective. 

Apparatus  Required. 

It  is  necessary  to  have  an  electrical  table-plate  or  switch-board  arranged  for  de- 
Uvering,  controlhng  and  measuring  the  current,  and  a  separate  converter  for  the 
cautery.  The  current  itself  is  preferably  supphed  from  a  suitable  street  current, 
if  that  is  available.  In  places  where  there  is  no  street  current,  dependence  must 
be  placed  in  cells  of  suitable  character  and  number,  placed  in  the  basement  or  else- 
where. 

Electrodes.  There  should  be  one  large  abdominal  electrode  made  of  sponge 
or  some  satisfactory  substitute.  Just  before  using  each  time  the  surface  of  the  elec- 
trode may  be  covered  with  a  layer  of  absorbent  cotton,  which  keeps  it  from  direct 
contact  with  the  skin  of  the  patient  and  thus  does  away  with  any  possibility  of 
contamination  from  one  person  to  another.  By  using  a  wide  thick  piece  of  ab- 
sorbent cotton,  the  contact  surface  of  the  electrode  may  be  increased  as  desired. 
This  increase  in  contact  surface  is  very  useful  for  the  abdominal  electrode  when 
giving  strong  currents. 

Two  vaginal  electrodes,  one  monopolar  and  one  bipolar,  are  required.  These 
may  be  used  also  as  rectal  electrodes. 

Two  intra-uterine  electrodes,  one  monopolar,  and  one  bipolar,  are  required. 
They  must  be  so  constructed  that  they  can  be  sterilized  each  time  before  use. 
The  intra-uterine  electrodes  may  be  used  also  as  urethral  electrodes. 

A  very  convenient  set  of  monopolar  electrodes  is  that  of  Goelet's.  There  are 
three  sizes  in  order  to  make  them  effective  in  the  treatment  of  cervical  stenosis 
and  persistent  menorrhagia  and  metrorrhagia. 

In  the  treatment  of  persistent  uterine  bleeding  the  effect  desired  is  a  mild  cau- 
terization of  the  endometrium.  This  is  secured  as  later  explained  by  a  current  of 
30  to  40  m.  a.,  the  intra-uterine  electrode  being  the  positive  pole.  When  the  posi- 
itive  pole  is  composed  of  copper  it  is  corroded  by  the  current  and  there  is  secured 
some  cataphoresis — that  is,  the  copper  salts  are  projected  slightly  into  the  adja- 
cent tissues,  increasing  the  beneficial  effect. 

For  regular  cautery  work  (excision  of  growths,  etc.)  it  is  necessary  to  have  a 
cautery  handle  with  two  cautery  points,  one  point  knife-like,  for  cutting,  and 
the  other  cone-shaped  for  touching  surfaces  superficially. 

Rules   of   Application. 

1.  Study  your  electrical. outfit  and  experiment  with  it  until  you  are  acquainted 
with  all  its  component  parts  and  know  by  experience  what  it  will  do  under  ordi- 
nary circumstances.  You  can  not  get  this  knowledge  by  reading  a  description  of 
the  apparatus  and  the  directions  for  operating  it.  It  can  be  acquired  only  by 
actually  handling  and  experimenting  with  it. 

2.  Wherever  an  electrode  is  to  be  applied  to  the  skin,  the  skin  and  the  electrode 
should  be  well  moistened.  If  this  precaution  is  not  taken,  there  will  be  consider- 
able pain  and  not  much  current,  for  the  dry  skin  is  a  poor  conductor  of  electricity. 


RULES  FOR  THE  APPLICATION  OF  ELECTRICITY  355 

See  that  there  is  no  current  until  everything  is  in  place.  Adjust  the  electrodes 
in  place  before  connecting  them  with  tiie  battery.  When  connecting  them  with 
the  battery  see  that  the  current  is  entirely  shut  off. 

3.  After  the  electrodes  are  in  place  and  connected  by  the  conducting  cords  with 
the  battery,  then  by  means  of  the  current  controller  turn  the  current  on  very  grad= 
ually.  If  the  patient  complains  of  pain  while  there  is  only  a  small  current,  it 
means  that  there  is  poor  contact  or  too  small  an  area  of  contact  between  one  of  the 
electrodes  and  the  patient.  If  the  indicator  of  the  milliamperemeter  fails  to  move 
up,  it  means  that  there  is  a  break  somewhere  and  that  there  is  no  current  passing 
between  the  electrodes.  Turn  on  only  a  very  small  current  until  it  is  seen  that 
everything  is  working  nicely  and  then  the  strength  may  be  gradually  increased  to 
the  desired  amount. 

4.  Indifferent  electrode.  In  all  pelvic  applications,  where  two  electrodes  are 
used,  the  larger  electrode  is  placed  on  the  lower  abdomen  or  on  the  back  in  the 
lumbar  or  sacral  region.  It  is  disposed  in  relation  to  the  active  electrode  so  that 
the  current  will  pass  through  the  affected  tissues.  Consequently,  in  most  cases  it 
is  placed  over  the  lower  abdomen.  This  large  electrode  is  called  the  indifferent 
electrode  because  there  is  no  particular  effect  near  it.  It  must  be  large  enough 
(must  spread  over  enough  skin  surface),  to  carry  the  required  strength  of  current 
without  marked  irritation  of  the  surface.  If  the  contact  area  is  too  small  for  the 
strength  of  current,  the  skin  becomes  very  red  and  the  patient  complains  of  ting- 
ling or  burning.  In  cases  where  a  counter-irritant  effect  on  the  skin  is  desired,  a 
strong  current  with  an  undersized  electrode  may  be  used  for  that  purpose.  Ordi- 
narily, however,  the  indifferent  electrode  should  be  so  large  that  there  is  no  effect 
on  the  skin  beyond  a  slight  tingling  and  a  temporary  redness.  If  any  metal  part 
of  an  abdominal  electrode  comes  in  contact  with  the  skin,  while  a  strong  current 
is  passing,  it  will  cause  a  burn  and  resulting  blister. 

5.  The  active  electrode  is  the  internal  one,  the  one  in  the  uterus  or  vagina  or 
urethra  or  rectum  as  the  case  may  be.  If  the  application  is  wholly  external,  the 
smaller  of  the  two  electrodes  is  the  active  one  and  is  usually  placed  nearest  the  seat 
of  the  lesion  or  the  pain  (the  external  applications  are  usually  made  for  pain),  the 
larger  electrode  (indifferent  electrode)  being  placed  opposite  on  the  abdomen  or 
on  the  back. 

The  internal  electrodes  (intra-uterine,  vaginal,  urethral,  rectal)  are  ordinarily 
used  bare  so  that  the  metal  comes  in  direct  contact  with  the  adjacent  surface.  In 
cases  of  vagino-abdominal  or  vagino-dorsal  application  in  which  it  is  desired  to 
use  a  strong  current,  the  vaginal  electrode  is  wrapped  with  absorbent  cotton  which 
is  well  moistened  before  introduction.  By  increasing  the  amount  of  the  wrapping, 
the  contact  surface  of  the  vaginal  electrode  (and  consequently  the  strength  of  the 
current  that  may  be  used  without  discomfort)  may  be  increased  as  desired. 

6.  The  active  electrode  is  the  positive  pole  when  it  is  giving  the  current  to  the 
other  one,  it  is  the  negative  pole  when  it  is  receiving  the  current  fromthe  other  one. 

The  active  electrode  is  made  positive  or  negative  as  desired  by  means  of  the  pole 
changer. 

7.  The  local  effects  of  the  positive  pole  are  to  diminish  the  amount  of  blood  in 


356  GYNECOLOGIC  TREATMENT 

the  immediately  adjacent  tissues  (checks  hemorrhage  and  lessens  congestion)  and 
to  relieve  pain.  It  is  used  to  check  uterine  bleeding  due  to  endometritis,  subin- 
volution, or  fibroids,  and  to  relieve  pain  due  to  congestion,  old  inflammatory 
trouble  or  neuralgia. 

The  local  effects  of  the  negative  pole  are  to  increase  the  amount  of  blood  in  the 
immediately  adjacent  tissues.  Consequently,  it  causes  active  congestion,  in- 
creases functional  activity,  increases  growth  and  hastens  the  absorption  of  chronic 
exudates.  It  is  used  in  cases  of  amenorrhoea,  scanty  menstruation,  poor  devel- 
opment of  uterus  or  ovaries,  and  for  plastic  or  serous  exudates  remaining  in  the 
pelvis  after  acute  symptoms  have  long  subsided. 

The  relative  quality  of  action  of  the  two  poles  is  about  the  same  for  both  the 
galvanic  and  faradic  currents. 

8.  With  the  faradic  current,  one  may  use  either  the  primary  or  secondary  current. 
The  primary  current  is  more  stimulating  and  is  used  to  overcome  relaxation  of 

tissues  and  to  increase  functional  activity. 

The  secondary  current  is  more  sedative  in  its  effect  and  is  used  to  relieve  pain 
due  either  to  congestion  or  to  neuralgic  conditions.  With  the  faradic  current 
there  is  another  disposition  of  the  poles,  namely,  the  placing  of  the  two  close  to- 
gether in  the  same  electrode.  This  constitutes  the  bipolar  electrode.  Used  with 
the  secondary  current,  it  is  especially  effective  in  reheving  local  pain. 

9.  The  various  locations  of  the  electrodes  for  pelvic  treatment  may  be  desig- 
nated as  follows.* 

On    External    Surfaces — Dorso-abdominal,    Sacro-abdominal,    Perineo-abdom- 

inal,  Perineo-dorsal. 

In  Vagina — Vagino-abdominal,  Vagino-dorsal,  Bipolar  vaginal. 

In  Uterus — Intrauterine-abdominal,   Intrauterine-dorsal,   Bipolar   intrauterine,- 

In  Rectum — Recto-abdominal,  Recto-dorsal,  Bipolar  rectal. 

In  Urethra — Urethro-abdominal,  Urethro-dorsal,  Bipolar  urethral. 

Other  methods  of  application  such  as  general  galvanization  and  general  faradiza- 
tion and  appUcations  of  static  electricity,  while  frequently  useful  in  the  treatment 
of  certain  conditions  associated  with  gynecological  diseases,  belong  to  general 
medicine  and  will  not  be  described  here. 

10.  Manner  of  using  electricity  for  the  different  affections. 

a.  For  uterine  bleeding  (menorrhagia  or  metrorrhagia),  uterine  leucorrhoea  or 
chronic  congestion,  use  the  galvanic  current,  positive  pole  in  uterus,  strength  of 
current  20  to  50  m.  a.,  duration  five  to  ten  minutes,  and  repeat  once  a  week  or  twice 
a  week  or  every  other  day  as  necessary. 

b.  For  amenorrhoea,  scanty  menstruation,  poorly  developed  uterus,  atonic 
conditions  of  uterus  or  vagina  or  pelvic  floor  muscles  or  sphincter  ani  (when  re- 
paired after  long  non-use)  or  sphincter  vesicae  (when  weak  from  damage  in  par- 
turition or  other  cause),  use  the  galvanic  current,  negative  pole  in  uterus,  strength 
of  current  20  to  50  m.  a.,  duration  five  to  ten  minutes,  and  repeat  once  a  week  or 
twice  a  week  or  every  other  day  as  necessary. 

Use  faradic  current,  primary  current  and  negative  pole  in  uterus. 
Use  faradic  current,  primary  current  and  negative  pole  in  vagina. 
Use  faradic  current,  bipolar  application  in  uterus  or  vagina. 


RULES  FOR  THE  APPLICATION  OF  ELECTRICITY  357 

In  all  cases  be  very  careful  to  exclude  pregnancy  before  using  this  treatment. 
When  treating  for  atony  of  the  sphincter  ani  and  accessory  muscles,  the  vaginal 
electrodes  may  be  used  as  rectal,  the  active  portion  of  the  electrode  being  placed 
so  as  to  direct  the  current  through  the  affected  muscles.  When  treating  for  imper- 
fect control  of  the  urine,  the  intra-uterine  electrodes  may  be  used  as  urethral. 

c.  To  overcome  stenosis  of  cervical  canal,  use  galvanic  current,  negative  pole, 
strength  of  current  5  to  10  m.  a.,  duration  10  to  20  minutes  and  use  twice,  with  a 
3  to  5  day  interval,  just  before  the  menstrual  time,  when  no  chance  of  pregnancy. 

The  electrode  is  introduced  to  the  stenosis  and  then  the  current  turned  on  grad- 
ually. The  effect  of  the  negative  pole  is  to  cause  congestion  and  softening  of  the 
tissues.  The  electrode  is  kept  gently  pressed  against  the  area.  It  gradually 
advances  as  the  tissues  in  front  of  it  soften. 

d.  To  relieve  pain  due  to  dysmenorrhoea,  chronic  pelvic  inflammation  or  con- 
gestion, use  the  positive  pole  in  the  uterus  or  vagina  with  galvanic  or  faradic  cur- 
rent. Also  faradic  bipolar  application  with  secondary  current.  If  due  to  ane- 
mia, poor  development  or  poor  functional  activity,  use  the  negative  pole  in  uterus 
or  vagina  with  galvanic  or  faradic  secondary  current.  Also  faradic  bipolar  appli- 
cation in  uterus  or  vagina  with  secondary  current.  If  without  distinct  local  lesion, 
i.  e.,  coming  under  the  class  styled  neuralgic,  try  the  different  methods.  The  far- 
adic bipolar  application  with  secondary  current  is  especially  effective  in  relieving 
localized  pain,  when  the  electrode  can  be  brought  close  to  the  painful  area.  The 
advice  to  try  the  different  methods  is  applicable,  in  a  measure,  in  nearly  all  appli- 
cations of  electricity  to  gynecological  treatment,  when  the  method  first  used  does 
not  produce  the  desired  result.  Each  case  is  to  some  extent,  a  "mixed  case,"  i.  e., 
there  are  several  separate,  and  sometimes  opposed,  factors  at  work  and  it  is  often 
difficult  to  say  which  is  the  predominating  one. 

e.  For  excision  or  destruction  of  tissue,  such  as  small  condylomata  about  the 
external  genitals,  caruncle  about  the  urethra,  persistent  erosion  about  the  cervix, 
small  cervical  cysts,  cervical  polypi,  etc.,  the  cautery  is  employed.  Use  the 
cautery-knife  for  excising  papillomata  and  puncturing  cysts,  and  the  cone-shaped 
cautery-point  for  searing  areas  requiring  such  treatment.  If  on  a  sensitive  surface, 
as  on  the  external  genitals  or  on  the  vaginal  wall,  apply  a  20  per  cent,  cocaine 
solution  or  inject  a  J  per  cent,  cocaine  solution  at  the  base  of  the  involved  tissue. 

11.  The  desired  effect  should  be  obtained  with  as  little  local  disturbance  as  pos- 
sible— that  is,  in  a  case  where  the  desired  result  can  be  obtained  by  dorso-abdom- 
inal  applications  (as  in  some  cases  of  general  pelvic  pain  due  to  chronic  pelvic  in- 
flammation, pelvic  neuralgia,  etc.)  these  should  be  used  in  preference  to  vaginal 
or  intra-uterine  applications,  especially  in  the  case  of  unmarried  women.  On  the 
same  principal,  an  intra-uterine  application  is  not  used  when  a  vag'nal  application 
will  suffice. 

Furthermore  the  strength  of  the  application  should  not  be  such  as  to  cause  pain, 
the  limit  for  that  particular  patient  being  found  by  gradual  increase  of  the  current 
strength  by  means  of  tho  controller  (rheostat).  Start  with  a  very  slight  current, 
barely  enough  to  move  the  indicator,  until  it  is  seen  that  everj'thing  is  working 
smoothl}'.  Then  increase  very  gradually  as  the  patient  becomes  accustomed  to 
the  current.     This  special  care  to  give  not   the  slightest  discomfort  is  particularly 


358  GYNECOLOGIC  TREATMENT 

important  at  the  first  application,  as  some  patients  are  very  uneasy  when  under 
treatment  by  electricity  until  it  has  been  demonstrated  to  them  that  there  is  no 
pain  or  shock. 

The  duration  of  the  application  should  not  be  sufficient  to  cause  fatigue  or  much 
subsequent  irritation,  the  usual  duration  being  10  to  20  minutes. 

The  frequency  of  the  application  varies  very  much  in  different  cases.  The 
milder  application  may  be  made  twice  a  week  or  every  other  day  or  even  every  day 
for  special  indications.  The  stronger  currents  should  be  applied  less  frequently, 
as  once  a  week  or  every  ten  days  or  two  weeks. 

12.  Strict  attention  should  be  given  to  cleanliness.  The  electrodes  for  internal 
use  (intra-uterine,  vaginal,  urethral,  rectal)  are  sterilized  and  used  under  the  same 
strict  precautions  as  other  instruments  for  the  same  localities. 

13.  Remember  that  electricity  is  not  a  cure=all.  It  is  only  one  of  our  many  re- 
sources. Some  affections  in  some  patients  are  benefitted  by  it.  Many  are  not 
benefitted.  Our  duty  in  each  case  of  disease  is  to  cure  the  patient,  or  give  her  re- 
lief, by  the  safest  and  most  effective  means.  Consequently  in  those  cases  where 
electricity  promises  the  best  results  it  should  be  given  a  thorough  trial,  but  in  those 
cases  for  which  we  have  better  means  no  time  should  be  wasted  with  it. 

CERVICAL  DILATATION. 

The  thorough  dilatation  under  anesthesia  which  precedes  curetment  is  con- 
sidered in  chapter  vi. 

Partial  dilatation  in  the  office  may  give  considerable  relief  in  cases  of  dysmenor- 
rhoea  and  it  is  used  also  in  the  treatment  of  sterility.  The  methods  of  making 
partial  dilatation  are  given  in  chapter  i  and  in  chapter  xiv. 

VACUUM  TREATMENT. 

Suction  has  been  applied  to  the  uterine  cavity  by  means  of  an  apparatus  fitting 
over  the  cervix  and  extending  into  the  cavity.  By  means  of  a  suction  pump  the 
uterine  secretion  is  drawn  out  and  a  partial  vacumn  created,  causing  passive  con- 
gestion of  the  endometrium.  It  is  an  application  of  Bier's  "congestion  treat- 
ment, "  which  has  been  found  so  useful  in  certain  general  surgical  affections.  It 
has  been  used  principally  in  the  treatment  of  chronic  endometritis.  The  reported 
cases  show  that  the  treatment  must  be  long  continued  and  the  results  finally 
secured  are  apparently  no  better,  if  as  good,  as  those  given  by  the  more  common 
and  less  tedious  therapeutic  methods. 

APPLICATIONS  WITHIN  RECTUM. 

ENEMATA,  LOW  AND  HIGH. 

The  use  of  low  enemata  for  emptying  the  rectum  is  so  common  and  well  known 
as  to  require  no  description.  It  may  be  well,  however,  to  point  out  that  in  all  pain- 
ful affections  of  the  rectum, an  enema  of  two  to  four  ounces  of  olive  oil  or  sweet  oil, 
with  or  without  the  addition  of  a  pint  of  plain  water,  is  preferable  to  the  soap-water 
enema  ordinarily  employed. 


PELVIC  TREATMENT  PER  RECTUM 


;^59 


High  enemata  are  useful  in  several  ways.  Plain  water  or  soap-water  or  medi- 
cated solutions  are  used  in  this  way  to  secure  bowel  movement  in  obstinate  cases. 
Normal  saline  solution  is  thus  used  after  serious  operations,  to  relieve  thirst,  to  aid 
the  kidney  action  and  to  sustain  the  heart,  ^'arious  nutrient  mixtures  are  used 
as  hiirh  enemata  to  nourish  the  patient  in  certain  classes  of  cases. 

It  is  in  the  after-treatment  of  .serious  operative  cases  that  high  enemata  are  prin- 
cipally employed  in  gj'necological  work.  The  indications  for  their  employment 
are  given  under  After-treatment  of  Operative  Cases  (chapter  xvi)  and  formulae 
for  the  same  are  given  in  the  Appendix. 

HOT  WATER  IRRIGATION  OF  RECTUM. 

The  use  of  hot  water  or  hot  saline  solution  in  the  rectum  has  been  found  useful 
in  two  classes  of  gjmecological  cases,  first,  those  presenting  a  large  mass  of  inflam- 
matory exudate  that  resists  absorption  and,  second,  those  presenting  acute  gen- 
eral peritonitis. 

For  Pelvic  Exudate.  In  these  cases  the  effect  desired  is  the  same  as  that  sought 
by  the  long  hot  vaginal  douche,  namely,  the  long  application  of  moist  heat  in  the 
immediate  vicinity  of  the  mass  of  exudate.  In  some  cases  the  hot  water  may  be 
brought  closer  to  the  mass  and  made  more  effective  by  rectal  irrigation  than  by 
vaginal  irrigation.  The  rectal  douche  must  differ,  however,  in  some  particulars 
from  the  vaginal  douche.  On  account  of  the  sphincter  ani  muscle,  a  double  irri- 
gating tube  should  be  used.  Again,  the  rectal  mucosa  is  easily  irritated  and, 
furthermore,  it  is  an  absorbent  surface,  hence  no  strong  antiseptic  solution  is  per- 
missible there.  The  irrigating  fluid  should  be  simply  plain  water  or  normal  saline 
solution. 

For  Sepsis.  Here  the  effect  desired  is  absorption  of  the  saline  solution  into  the 
general  circulation,  for  aiding  the  kidneys  and  heart,  and  also  to  some  extent 
absorption  of  the  saline  into  the  peritoneal  cavity  and  out  with  the  drainage, 
instead  of  absorption  of  septic  material  from  the  cavity  into  the  general  circu- 
lation.    For  details,  see  Treatment  of  Acute  Pelvic  Inflammation  (chapter  x). 

APPLICATIONS  TO  THE  LOWER  ABDOMEN  AND  INTERIOR 

OF  PELVIS. 

PELVIC  MASSAGE. 

Pelvic  massage  is  the  application  of  the  principles  of  massage  to  the  intrapelvic 
structures. 

The  effects  to  be  attained  are: 

Correction  of  displacement  of  the  uterus,  tubes  and  ovaries. 

Stretching  of  adhesions  and  infiltrated  tissues. 

Improvement  of  pelvic  circulation  (lymph  and  blood). 

Absorption  of  chronic  exudates. 

Details  of  Application. 

I  think  the  best  way  to  introduce  this  important  therapeutic  method  is  to  con- 
sider it  as  a  continuation  of,  or  addition  to,  the  ordinary  bimanual  examination. 


3Q0  GYXECOLOGIC  TREATMENT 

When  there  is  displacement  of  the  uterus,  with  or  without  adhesions,  the  bimanual 
examination,  by  which  the  diagnosis  is  estabUshed,  has   also  a  therapeutic  value. 

Take,  for  example,  a  case  of  retrodisplacement  in  which  the  uterus  can  be  brought 
forward  but  vdW  not  stay  there.  By  bringing  the  uterus  forward  in  the  bimanual 
examination,  the  diagnosis  of  movable  retrodisplacement  is  established.  Then 
search  is  made  to  discover  why  the  uterus  will  not  stay  forward.  Suppose  it  is 
found  that  the  anterior  vaginal  wall  or  vesico-vaginal  septum  is  shortened,  as 
sometimes  happens.  Whether  this  is  a,  primary  or  secondary  change  is  not  of 
so  much  importance  as  to  the  fact  that  it  exists,  and  constantly  keeps  the  cervix  so 
far  forward  that  the  fundus  uteri  tends  to  go  backward.  Of  course,  when  in  the 
bimanual  examination  the  fundus  is  brought  forward,  the  cervix  is  pushed  back- 
ward and  upward  and  the  fundus  is  at  the  same  time  bent  forward  over  the  tips  of 
the  examining  fingers  in  the  anterior  fornix,  to  take  out  any  flexion  in  the  body  of 
the  uterus. 

Now,  if  instead  of  ceasing  this  intra-pelvic  work  as  soon  as  the  diagnosis  is  estab- 
lished, we  continue  to  stretch  the  shortened  vesico-vaginal  septum,  a  decided 
therapeutic  effect  tending  to  permanent  correction  of  the  displacement  is  secured. 
The  contracted  tissues  anterior  to  the  cervix  are  made  tense  and  stretched  even  up 
to  the  point  of  painfulness,  and  we  endeavor  all  the  time  to  place  the  cervix  farther 
back  in  the  pelvis  as  the  tissues  gi-adualty  yield.  Force  sufficient  to  damage  the 
tissues  or  cause  severe  pain  should  not  be  used,  the  object  being  to  gradually 
lengthen  the  tissues  as  much  as  possible  without  damage.  In  doing  this  we  per- 
form one  of  the  important  manipulations  of  pelvic  massage,  namely,  stretching. 
This  stretching  may  be  done  with  the  vaginal  fingers  alone,  but  the  holding  of  the 
fundus  uteri  well  forward  at  the  same  time,  with  the  fingers  of  the  abdominal  hand, 
makes  it  more  effective.  There  may  be  a  restricting  band  running  obliquely 
toward  one  obturator  foramen,  or  transvei-sety  toward  the  pelvic  wall  in  the  base 
of  the  broad  ligament.     Whatever  the  direction  of  the  band,  it  is  to  be  stretched. 

This  process  of  stretching  is  somewhat  painful  and  maj'  be  followed  by  a  sense 
of  fullness  and  pain  in  the  stretched  structures.  It  has  been  found  by  experience 
that  these  discomforts  are  climinished  and  the  softening  and  stretching  of  the  tense 
tissues  facilitated  by  sweeping  pressure,  so  directed  as  to  work  the  lymph  and 
venous  blood  out  of  the  tissues  toward  the  pelvic  wall.  This  permits  the  more 
rapid  entrance  of  fresh  blood  and  hastens  the  absorption  of  serous  and  cellular  in- 
fi'tration.  This  sweeping  pressure  is  applied  by  the  finger-tips  or  the  knuckles  of 
the  abdominal  hand,  worked  far  down  into  the  pelvis  to  the  tissues  under  treat- 
ment. The  fingers  of  the  abdominal  hand  depress  the  abdominal  wall  to  the  af- 
fected tissues,  which  tissues  are,  at  the  same  time,  raised  as  much  as  possible  by 
the  vaginal  fingers.  The  infiltrated  tissues  are  now  compressed  between  the  va- 
ginal and  abdominal  fingers.  The  abdominal  fingers,  still  keeping  up  the  pressure, 
are  made  to  describe  a  small  circle  or  ellipse.  In  the  lower  part  of  the  circle,  which 
lias  directly  over  the  ti.ssues  under  treatment  and  where  the  direction  of  movement 
is  from  within  outward,  the  strong  pressure  is  made.  In  this  movement,  the  ab- 
dominal fingers  remain  at  the  same  spot  on  the  skin.  This  is  essential  for,  if  the 
pressure  is  relaxed  enough  to  allow  the  fingers  to  slip  over  the  abdominal  surface, 
no  deep  effect  can  be  obtained.     The  skin  is  freely  movable  over  the  deeper  struc- 


DETAILS  OF  PELVIC  MASSAGE 


:ni\ 


tures  of  the  abdominal  wall,  and  one  point  can  easily  be  carried  through  the  small 
circle  described.  In  some  cases,  where  the  abdominal  wall  is  very  thin  and  lax, 
the  whole  thickness  of  the  wall  may  follow  the  fingers  to  some  extent.  The  va- 
ginal fingers  are  not  moved  in  the  least.  They  remain  perfectly  stationary,  being 
required  only  to  elevate  the  infiltrated  area  so  that  it  can  l)e  subjected  to  com- 
pression by  the  fingers  above.  The  application  of  this  sweeping  pressure,  as  just 
described,  constitutes  that  other  important  manipulation  of  massage  known  as 
kneading. 

These  two  manipulations,  stretching  and  kneading  of  shortened  and  infiltrated 
tissues  or  of  adhesions,  constitute  the  essentials  of  pelvic  massage  in  ordinary 
cases.  Whether  the  infiltrated  area  or  the  tense  band  is  at  the  lower  part  of  the 
broad  ligament  or  the  upper  part,  whether  it  binds  the  uterus  backward  or  forward 
or  laterally  or  holds  an  ovary  or  tube  in  abnormal  position,  the  principles  of  manip- 
ulation are  the  same,  namely,  to  stretch  the  adhesions  or  shortened  tissues  and  to 
work  the  lymph  and  venous  blood  out  of  them  towards  the  pelvic  wall.  The 
clothing  must  be  well  loosened  so  that  there  is  no  constriction  forcing  the  intes- 
tines into  the  pelvis.  The  bladder  and  rectum  should  be  empty — therefore  direct 
the  patient  to  take  an  enema  an  hour  or  two  before  coming  for  treatment  and 
to  empty  the  bladder  just  before  treatment. 

The  manipulations  must  always  be  gentle  at  first,  gradually  increasing  in  force 
as  the  tenderness  diminishes.  Painful  points  should  not  be  passed  over  directly 
or  carelessly  but  circled  about  and  approached  gradually. 

As  to  the  length  of  the  seance  and  the  frequency  of  repetition,  the  ph3-sician  is 
guided  b}^  the  conditions  present  and  the  effect  produced.  The  idea  is  to  stretch 
the  tissues  and  remove  infiltration  as  quickly  as  po.ssible,  but  if  too  much  force  is 
used  or  the  seance  made  too  long  the  resulting  irritation  may  increase  rather  than 
diminish  the  infiltration.  The  treatments  should  be  far  enough  separated  so  that 
the  irritation  from  one,  as  evidenced  by  pain  and  soreness,  has  largely  subsided 
before  the  next  is  given.  This,  of  course,  will  varj^  much  in  different  cases.  A 
seance  of  five  or  ten  minutes  repeated  from  every  second  day  to  e^'ery  other  week, 
are  about  the  requirements.  The  cases  must  be  carefully  selected,  and  if  no  decided 
benefit  is  apparent  after  a  few  treatments,  they  are  stopped  and  more  effective 
measures  employed.  Of  course,  other  measures  are  to  be  used  in  conjunction  with 
this  treatment  as  indicated — general  measures,  internal  treatment,  hot  vaginal 
douches,  pessaries,  etc. 

Indications  for  Pelvic  Massage. 

Pelvic  massage  is  of  benefit  principally  in  cases  of  uterine  displacement  accom- 
panied by  the  sequelae  of  a  pelvic  cellulitis  (real  parametritis)  or  by  old  peritoneal 
adhesions  without  active  pelvic  inflammation.  It  is  useful  also  in  some  cases  of 
the  same  connective  tissue  or  peritoneal  inflammatory  sequelae  without  important 
displacement  of  the  uterus,  the  improvement  in  these  cases  being  due  probably 
to  the  removal  of  cellular  infiltration  and  stasis-edema  of  the  tissues,  the  relief 
from  pressure  of  constricting  peritoneal  bands  and  the  improvement  of  the  lymph 
and  blood  circulation  in  the  pelvis.     It  is  useful  also  in  exceptional  cases  of  a  per- 


362  GYNECOLOGIC  TREATMENT 

sistent  large  mass  of  exudate,  but  only  where  all  active  inflammation  has  disap- 
peared and  nature  has  failed  to  make  the  usual  prompt  removal  of  exudate  when 
it  is  no  longer  needed  for  limiting  purposes. 

Inflammation  of  the  connective  tissue  in  this  region,  as  in  other  regions,  runs  its 
course  rather  rapidly,  ending  in  resolution  or  in  the  formation  of  an  abscess  which 
is  opened  or  opens  itself.  In  either  case  the  active  inflammation  soon  subsides, 
leaving  no  persistent  focus  of  active  inflammation,  but  only  the  sequelae,  consist- 
ing principally  of  scar  tissue  and  cellular  infiltration  and  the  circulatory  disturb- 
ance of  lymph  and  blood  resulting  therefrom.  These  are  just  the  conditions  most 
susceptible  to  improvement  by  massage.  Furthermore,  in  this  condition  com- 
paratively Uttle  can  be  accompHshed  by  operative  work.  There  is  no  focus  of  per- 
sistent inflammation  to  be  excised,  no  intra-peritoneal  mass  of  exudate  to  be  re- 
moved, no  intra-peritoneal  bands  to  be  broken.  The  cellular  infiltration  and  the 
bands  of  scar  tissue  lie  under  the  peritoneum  among  important  vessels  and  nerves 
and  other  structures,  and  are  of  such  nature  and  so  situated,  that  their  excision  is 
not,  ordinarily,  desirable  nor  practicable. 

Allied  to  these  cases,  as  regards  their  suitableness  for  massage,  are  the  cases  of 
retrodisplacement  without  infection  in  which  the  persistence  of  the  displacement 
seems  to  be  due,  to  considerable  extent  at  least,  to  a  shortening  of  the  upper  pos- 
terior part  of  the  broad  ligament.  This  is  found  in  certain  troublesome  cases  of 
retrodisplacement  in  wornen  who  have  never  been  pregnant.  It  constitutes  the 
cause  of  failure  in  some  cases  submitted  to  the  ordinary  operative  procedures  for 
retrodisplacement.  It  is  not  effected  by  such  measures  unless  the  involved  tis- 
sues are  directly  divided  or  over-stretched  at  the  time,  and  this  must  be  done  care- 
fully or  important  structures  will  be  injured.  In  some  cases  this  contraction  is 
hardly  appreciable  during  the  operative  work,  the  uterus  coming  forward  without 
much  resistance,  but  the  constant  slight  pull  maintained  by  this  tense  tissue  is 
sufficient  to  gradually  draw  the  uterus  back  again  into  retrodisplacement.  In 
cases  of  retrodisplacement,  the  intra-pelvic  conditions  should  be  carefully  studied 
by  bimanual  examination,  to  determine  just  what  holds  the  uterus  backward  or 
what  causes  it  to  go  backward  after  replacement. 

On  the  other  hand,  when  an  infectious  process  attacks  the  Fallopian  tubes  there 
is  liable  to  remain  a  focus  of  persistent  inflammation,  the  same  as  there  does  in  the 
appendix.  It  may  be  walled  off  so  as  to  remain  in  a  measure  quiescent  for  weeks  or 
months  at  a  time,  but  every  once  in  a  while  it  is  stirred  up  by  extra  exertion  or 
some  other  circumstance  that  increases  the  local  irritation  or  diminishes  the  local 
resistance.  It  is  evident  that  in  such  a  condition  (salpingitis),  stretching  or  kneading 
of  the  involved  tissue  would  only  cause  an  increase  of  the  inflammation  and  of  the 
resulting  exudate  and  disturbance.  The  proper  tr.eatment  in  such  a  ca,se  is  to  re- 
move the  focus  of  persistent  inflammation,  and  this  is  accomplished  by  the  removal 
of  the  diseased  tube  oi'  ovary  and,  as  far  as  practicable,  of  the  accompanying  peri- 
toneal  exudate. 

Just  a  word  as  to  the  term  "  parametritis, "  for  it  looms  up  large  in  nearly  all  arti- 
cles on  pelvic  massage.  The  connective  tissue  about  the  uterus  and  extending  out 
into  the  broad  ligaments  and  sacro-uterine  ligaments,  is  often  spoken  of  collect- 
ively as  the  "parametrium" — a  very  convenient  term,  for  it  is  much  shorter  than 


INDICATIONS  FOR  PELVIC  MASSAGE  363 

"pelvic  connective  tissue"  or  "peri-uterine  connective  tissue,"  with  whidi  it  is 
synonymous.  Inflammation  of  the  connective  tissue  about  the  uterus  (pelvic 
cellulitis)  is  often  spoken  of  as  "parametritis."  So  far  so  good,  for  this  also  is 
a  convenient  term,  but  with  its  extended  use,  confusion  has  crept  in.  In 
the  first  place,  it  is  very  similar  in  sound  and  appearance  to  the  term  "perimet- 
ritis," which  means  inflamnuitionof  the  tissues  around  the  uterus,  more  especially, 
however  of  the  peritoneum  and  adnexa  (tubes  and  ovaries).  So,  even  with  a  per- 
fectly clear  idea  of  the  limitation  of  parametritis,  it  may  be  confounded  by  the 
hearer  or  reader  with  the  very  similar  sounding  and  appearing  word  "perimetri- 
tis," which  means  almost  the  opposite.  In  the  second  place,  the  term  paramet- 
ritis is  used  loosely  b}^  some  writers  and  speakers,  which  has  led  to  ambiguity  and 
much  difference  of  opinion  as  to  the  efficiency  of  pelvic  massage  and  other  methods 
of  treatment  in  pelvic  inflammatory  troubles.  There  seems  to  be  a  tendency  to 
apply  the  term  parametritis  to  every  thickening  or  induration  around  the  uterus. 
This  is  inexact  and  leads  to  misunderstanding  and  confusion.  If  persisted  in  to 
any  great  extent,  it  will  necessitate  the  dropping  of  this  very  useful  and  con- 
venient term.  In  speaking  to  my  classes  I  usually  employ  the  less  convenient 
term  "pelvic  cellulitis,"  because  only  one  meaning  can  be  attached  to  it. 

In  regard  to  pelvic  massage,  so  much  has  been  claimed  for  it  and  on  the  other 
hand  so  much  has  been  said  against  it,  that  the  beginner  is  very  liable  to  be  misled 
by  one  sided  reading  or  confused  by  the  vigorous  promulgation  of  conflicting  views. 
The  markedly  denunciatory  statements  indulged  in  on  each  side  are  in  many 
cases  the  result  of  one-sided  experience.  One  physician  prefers  operative  treat- 
ment, uses  it  exclusively  and  denounces  massage,  about  which  he  knows  little  or 
nothing.  Another  physician  favors  massage,  uses  it  exclusively  and  denounces 
operative  treatment,  about,  which  he  knows  little  or  nothing.  Of  course,  such  a 
state  of  affairs  should  not  exist,  but  the  fact  remains  that  it  does  exist,  not  only  in 
regard  to  this  subject  but  also  in  regard  to  other  important  subjects.  It  is  so  flat- 
tering to  one's  vanity  to  give  a  sweeping  opinion  on  a  subject  of  importance  and 
so  easy  to  find  auditors,  that  many  persons  make  broad  statements  without  proper 
thought  and  investigation.  Such  opinions  are  of  course  worthless,  but  the  fact 
that  they  are  worthless  is  often  not  known  to  th'osewho  hear  and  read  them,  and 
the  situation  is  thus  complicated  and  the  truth  obscured.  Differences  of  results 
and  consequently  differences  of  opinion  will  always  exist  on  account  of  differences 
in  physicians  and  patients,  but  we  should  always  be  ready  to  consider  a  subject  in 
a  rational  way  and  without  prejudice.  Persons  and  conditions  vary  so  much  and 
there  are  so  many  sources  of  error  that  we  must  advance  cautiously  from  the  well 
established  to  the  comparatively  unknown.  When  however  a  method  of  treat- 
ment is,  from  its  demonstrated  effect,  rationally  applicable  to  a  known  patho- 
logical condition,  and  hundreds  of  thoroughly  reliable  physicians  in  various  parts 
of  the  world  have  secured  good  results  by  practical  application  of  the  method, 
there  is  no  reason  why  it  should  not  be  used  where  the  necessary  skill  and  dis- 
crimination can  be  obtained.  A  method  is  not  condemned  because  some  have 
employed  it  as  a  cure-all,  when  in  fact  it  is  applicable  to  only  a  small  proportion  of 
the  conditions  met  with,  or  because  some  have  used  it  in  conditions  where  it  was 
contra-indicated  and  have  thereby  done  harm,  or  because  some  who  were  unworthy 


364  GYNECOLOGIC  TREATMENT 

the  name  of  physician  have  used  it  as  a  cloak  for  criminal  practices,  just  as  the  same 
or  similar  creatures  have  used  other  well-established  therapeutic  measures. 

Pelvic  massage  has  its  strict  indications  and  contra-indications,  just  as  has 
every  other  therapeutic  measure.  Its  application  requires  much  discrimination 
in  the  selection  of  cases  and  much  skill  in  the  pelvic  manipulations  and  then  a  large 
fund  of  patience  and  perseverence.  Used  with  skill  and  care  in  conjunction  with 
the  other  measures,  it  has,  in  certain  conditions  already  indicated,  restored  the 
patient  from  a  condition  of  chronic  invalidism  to  health,  and  to  a  condition  much 
nearer  anatomical  and  physiological  cure  than  could  have  been  secured  by  a  cut- 
ting operation.  In  other  cases  the  patient  is  not  cured,  but  the  intra-pelvic  con- 
dition is  so  far  improved  that  she  is  made  fairly  comfortable  and  able  to  get  along. 
In  still  other  cases  it  does  no  good  and  is  a  waste  of  time,  and  serves  to  postpone 
the  employment  of  measures  that  would  be  effective  in  restoring  the  patient's 
health. 

Contra=Indications  to  Pelvic  Massage. 

When  there  is  marked  tenderness  or  where  there  is  marked  hyperesthesia  of  the 
pelvic  organs  or  of  the  vagina  or  of  the  external  genitals,  pelvic  massage  is  contra- 
indicated.     It  is  contra-indicated  also  in  the  presence  of: — 

Acute  inflammation. 

A  collection  of  pus. 

Active  salpingitis. 

Pelvic  tuberculosis. 

Malignant  disease. 

Pregnancy, 

PRESSURE  TREATMENT. 

The  effects  sought  by  pressure  treatment  are  (a)  to  hasten  the  absorption  of  a 
chronic  exudate  in  the  pelvis,  (b)  to  assist  in  stretching  adhesions  or  infiltrated 
tissues  and  (c)  to  assist  in  raising  a  displaced  uterus. 

The  articles  required  are  (a)  two  strong  colpeurynters  connected  by  a  stop- 
cock, (b)  two  pounds  of  mercury,  (c)  bag  of  fiine  shot  weighing  three  pounds,  with 
an  elastic  bandage  for  fastening  same  to  the  lower  abdomen.  The  empty  col- 
peurynter  is  introduced  into  the  vagina,  the  patient's  hips  elevated,  the  shot-bag 
applied  to  the  lower  abdomen,  and  the  mercury  run  into  the  vaginal  colpeurynter 
in  sufficient  quantity  to  make  the  desired  pressure. 

Details  of  Application. 

The  bladder  and  rectum  must  be  empty.  With  the  patient  in  the  dorsal  pos- 
ture on  a  bed  or  table,  one  colpeurynter  (detached  from  the  other  and  empty)  is 
cleansed,  lubricated,  folded,  grasped  with  a  uterine  dressing  forceps  and  intro- 
duced to  that  portion  of  the  vaginal  vault  nearest  the  exudate.  The  patient  then 
takes  the  position  to  be  maintained  during  the  treatment — on  her  back,  if  the  ex- 
udate is  behind  the  uterus,  or  on  the  side  corresponding  to  the  exudate  if  it  is  on 
one  side  of  the  uterus — and  the  shot-bag  is  placed  on  the  lower  abdomen  and  so 


INDICATIONS  rOR  PRESSURE  TREATMENT  365 

fastened  by  a  bandage  or  elastic  belt  that  it  will  maintain  the  counter-pressure  in 
the  direction  of  the  exudate  when  the  patient's  hips  are  elevated.  The  foot  of 
the  bed  is  then  raised  about  eighteen  inches  and  the  hips  are  still  further  elevated 
by  one  or  two  folded  pillows  placed  under  them.  The  other  colpeurynter,  contain- 
ing the  two  pounds  of  mercury,  is  connected  with  the  colpeurynter  tube  extending 
out  of  the  vagina  and  the  stop-cock  is  opened  sufficiently  to  permit  a  small  stream 
of  mercury  to  flow  into  the  vaginal  colpeurynter  at  the  vaginal  vault.  From  one 
to  two  pounds  of  mercury  is  allowed  to  flow  into  the  vaginal  colpeurynter,  de- 
pending on  the  absence  of  pain.  There  should  not  be  enough  pressure  to  cause 
much  pain. 

The  treatments  are  given  daily  and  at  first  should  not  last  more  than  half  an 
hour,  to  be  soon  increased  to  one  hour.  Later,  if  well  borne,  the  treatment  may 
be  kept  up  for  several  hours  at  a  time — in  fact,  may  be  continued  the  greater  part 
of  the  day  with  intervals  of  rest. 

Indications  and  Contra=Indications. 

Indications.  Pressure  treatment  is  applicable  principally  in  cases  of  adherent 
retro-displacement  of  the  uterus  and  in  cases  of  chronic  pelvic  inflammation  in 
which  the  exudate  is  in  the  cul-de-sac  of  Douglas  cr  in  the  broad  ligament  or 
in  which  there  are  adhesions  low  in  the  pelvis. 

Contra=indications.  When  the  exudate  is  situated  high,  above  the  fundus 
uteri  or  about  the  tubes,  this  treatment  is  not  satisfactory. 

When  severe  pain  is  caused  by  the  pressure,  the  treatment  must  be  discon- 
tinued, as  there  is  danger  of  starting  up  active  inflammation  or  disseminating  an 
unrecognized  focus  of  active  infection.  It  is  contra-indicated  also  in  the  presence 
of:— 

Acute  inflammation. 

A  collection  of  pus. 

Active  salpingitis. 

Pelvic  tuberculosis. 

Malignant  disease. 

Pregnancy. 

APPLICATIONS  TO  BODY  GENERALLY. 

BATHING. 

Regular  bathing  for  hygienic  purposes  is  necessary  to  keep  the  patient  in  good 
general  health.  Also  hot  baths  or  cold  baths  may  be  required  for  their  special 
effect  on  the  patient's  nervous  system. 

The  hydrotherapeutic  methods  particularly  useful  in  gynecological  cases  (va- 
ginal douches,  moist  applications  to  lower  abdomen,  sitz  baths)  have  already 
been  described. 

FRICTION  RUBBING. 

Friction  rubbing  of  the  general  body  surface  with  alcohol  or  salt  or  a  brush  or 
a  rough  towel,  which  the  neurologists  have  found  so  extremely  useful  in  atonic 


366  GYNECOLOGIC  TREATMENT 

conditions  of  the  nervous  system  and  of  the  body  generally,  is  often  indicated  in 
gynecological  cases.  The  fact  that  the  patient  is  under  treatment  for  some  pelvic 
disease  should  not  prevent  her  receiving  such  other  treatment  as  is  necessary. 
After  operation  for  pelvic  disease  which  has  caused  marked  deterioration  of  the 
general  health,  it  is  important  to  employ  general  measures  in  conjunction  with 
the  local  measures  in  order  to  complete  the  restoration  to  health. 

The  detailed  consideration  of  these  various  general  measures  would  take  up 
too  much  room  and  would  be  somewhat  out  of  place  in  a  work  of  this  character.  I 
must  content  myself  with  calling  attention  to  the  importance  of  their  intelligent 
use  in  gynecological  cases. 

GENERAL  MASSAGE. 

General  massage  also  is  invaluable  in  the  treatment  of  certain  conditions  of  physi- 
cal depression  caused  by  or  associated  with  pelvic  disease.  The  cases  referred  to 
are  those  in  which  the  vital  forces  are  apparently  "  wornout "  by  long  suffering, 
chronic  septic  absorption,  autointoxication  or  faulty  metabolism.  The  object  is 
to  produce  a  general  tonic  effect  upon  the  muscular,  circulatory,  nervous,  diges- 
tive, respiratory  and  execretory  systems. 

General  massage,  like  other  general  measures,  belongs  to  general  medicine 
and  its  description  is  not  called  for  here. 

Pelvic  massage  has  already  been  considered. 

DRESS  CORRECTION. 

It  is  not  my  purpose  to  take  up  in  a  general  way  the  subject  of  dress  as  it  relates 
to  health.  I  want  simply  to  mention  two  things  that  have  a  bearing  on  the  treat- 
ment of  pelvic  disease. 

1.  Constriction  at  the  waist.  By  this  constriction  the  abdominal  contents  are 
forced  downward  towards  the  pelvis,  and  thus  the  pelvic  contents  are  sub- 
jected to  abnormal  pressure.  This  abnormal  pressure  interferes  with  the  circu- 
lation in  the  various  pelvic  organs,  causing  poor  nutrition  and  chronic  congestion. 

This  injurious  pressure  helps  to  bring  about  the  following  abnormal  conditions. 
In  the  young  woman,  the  nutrition  may  be  so  interfered  with  that  perfect  develop- 
ment is  not  attained.  In  the  adult,  the  chronic  pressure  and  congestion  tends  to 
cause  chronic  endometritis,  displacements  of  the  uterus  and  chronic  irritation  and 
enlargement  of  the  ovaries.  Following  parturition,  the  persistent  congestion 
tends  to  cause  subinvolution  and  chronic  endometritis.  In  laceration  of  the  pel- 
vic floor,  the  pernicious  effects  of  the  laceration  are  much  increased  by  the  con- 
stant strong  downward  pressure  of  the  abdominal  contents.  In  retrodisplacc- 
ments  of  the  uterus,  the  fundus  uteri  is  forced  still  further  into  the  abnormal  posi- 
tion by  this  downward  pros»i;re  from  above,  and  the  ovaries  also  are  forced  down 
beside  the  displaced  uterus.  In  prolapse,  the  structures  are  constantly  forced 
further  and  further  out  of  the  pelvis  and,  in  addition,  there  is  caused  a  general 
splanchnoptosis.  This  tendency  of  waist  constriction  to  cause  permanent  dis- 
placement of  various  abdominal  organs,  adds  many  abdominal  symptoms  to  those 
of  the  pelvic  disturbance. 


THE  KNEE-CHEST  POSTURE 


367 


2.  Dragging  weight  at  the  waist  line.  To  support  heavy  skirts  by  means  of  a 
string  tied  around  the  waist  is  fully  as  injurious  as  tlie  wearing  of  the  avei'age 
corset.  The  hea^•y  skirts  drag  down  the  abdominal  organs  towards  the  pelvis 
and  produce  injurious  pressure  on  the  pelvic  organs. 

To  prevent  these  injurious  effects,  all  constriction  should  be  removed  from 
about  the  waist  and  the  clothing  should  be  supported  from  the  shoulders,  as  has 
been  insisted  upon  so  strongly  by  those  who  have  given  much  careful  study  to 
the  relation  of  the  clothing  to  bodily  health,  strength  and  l^eauty.  This  is 
advisable  in  well  persons,  Init  is  imperatively  important  in  those  suffering 
with  pelvic  disorders.  Any  "corset"  or  "support"  or  "stay"  that  is  used,  should 
make  no  firm  constriction  above  the  iliac  crests.  Some  are  so  arranged  that  they 
not  only  cause  no  waist-constriction,  but  really  give  some  support  to  the  lower 
abdomen  and  hence  are  beneficial  in  cases  requiring  support. 

POSTURAL  METHODS  AND  EXERCISE. 

KNEE-CHEST  POSTURE. 

The  patient  supports  herself  on  the  knees  and  chest  (Fig.  468) .  The  head  rests 
on  a  pillow,  with  the  face  turned  to  one  side,  and  the  breasts  are  brought  as  closely 
as  possil)le  against  the  table.  The  clothing  must  be  well  loosened  about  the  ab- 
domen. The  thighs  should  be  vertical.  Unless  particular  attention  is  given  to 
the  latter  point  the  patient's  hips  will  be  too  far  forward  or  too  far  backward,  thus 


Fig.  468.     The   Knee-chest    Posture.     The  thighs  should  be  perpendicular  and  the  breasts  should  be  brought 
against  the  table.     All  constriction  about  the  waist  must  be  removed. 


368 


GYNECOLOGIC  TREATMENT 


losing  a  large  part  of  the  desired  elevation.     This  position  may  be  maintained  for 
from  one  to  ten  minutes. 

The  effect  of  this  posture  is  to  temporarily  take  all  downward  pressure  off  the 
pelvic  organs  and  permit  them  to  gravitate  toward  the  abdominal  cavity  (Fig. 
469).  The  downward  pressure  on  the  pelvic  organs  is  for  the  time  being  relieved, 
the  local  circulation  is  greatly  improved  and  a  movable  retrodisplaced  fundus 
uteri  tends  to  gravitate  forward  towards  the  normal  position.     The  effect  is  much 


Fig.  469.  The  Knee-chest  Posture,  showing  the  pelvic  structures  in  outhne  and 
illustrating  the  tendency  of  the  uterus  andadnexa  to  gravitate  forward.  (Montgomerj'— 
Practical  Gynecology.) 


Fig.  470.     The  Knee-chest  Posture,  with  the  patient  draped  ready  for  packing  or  other  treatment. 


INI)I<!ATIONS   FOR  THK  KN  i:i:-Clll-,S  I"   I'OSTUUE  360 

increased  if  the  vagina  be  opened  with  a  s](('ciiliiiii  or  with  the  fingers  so  that  air 
may  enter. 

Indications  for  Knee=Chest  Posture. 

The  knee-chest  posture  is  used  in  off  ice  treatment   for   the   following   purposes: 

To  assist  in  replacing  an  ordinary  movable  retrodisplaced  uterus. 

To  assist  in  replacing  a  pregnant  retrodisplaced  uterus. 

To  assist  in  pushing  a  tumor,  impacted  in  the  pelvis,  Ijack  into  the  abdominal 

cavity. 
To  assist  in  replacing  a  vaginal  hernia. 
To  hold  the  uterus  as  near  as  possiljle  to  normal  position  while  introducing  a 

vaginal  tamponade,  for  retrodisplacement  or  for  prolapse. 
Fig.  470  shows  the  patient   in   the    knee-chest   posture  and  draped  with    the 
sheet  for  treatment. 

The  knee-chest    posture  is  used  by    the   patient    at  home  as    an  aid    in   the 
treatment  of  the  following  conditions: 

Ketrodisplacement,  especially  when  the  uterus  can  not  be  entirely  replaced  or 

shows  a  tendency  to  return  to  the  backward  position. 
Downward  displacement  of  the  pelvic  organs,  from  laceration  of  the  pelvic  floor 
or  from  beginning  prolapse  or    from  simple    relaxation  and    intra-abdom- 
inal pressure. 
The  venous  congestion  and  consequent  heaviness  of  the  organs  is  for  the  time 
being  relieved  and  the  beneficial  effect  is  sometimes  noticed  for  hours  afterward. 
The    patient    is    directed  to  take  the  posture  ordinarily  for  one  or  two  minutes 
twice  daily.     Usually  the  most  convenient  time  is  while  in  bed.  just  after  retiring 
in  the  evening  and  just  before  rising  in  the  morning. 

TRENDELENBURG  POSTURE. 

In  the  Trendelenburg  posture  the  hips  are  elevated  as  showoi  in  Fig.  471.  The 
elevation  of  the  hips  may  be  moderate  or  extreme,  as  required  by  the  particular 
case.  This  posture  is  used  principally  in  operative  work,  though  it  is  sometimes 
useful  in  diagnosis  and  in  minor  gynecologic  treatment.  It  is  employed  in  the 
pressure- weight  treatment  previously  described,  in  pelvic  massage  in  certain  cases 
where  it  is  important  to  get  the  intestines  out  of  the  pelvis,  and  also  in  cases  where 
it  is  desired  to  employ  gravity  in  moving  an  abdominal  or  pelvic  organ  upwarrl 
towards  the  abdominal  cavity  but  in  which  the  patient  can  not  take  the  kneo- 
chest  posture. 

EXERCISE. 

General  Exercise.  Exercise  in  the  form  of  w^alking,  horse-back  riding,  driving, 
outdoor  games  and  general  gymnastic  movements  (both  outdoors  and  indoors) 
may  be  required  in  patients  presenting  pelvic  disturbance  depending  on  depres- 
sion of  the  general  health,  particularly  in  certain  forms  of  amenorrhoea.  These 
measures  are  used  however  almost  exclusively  for  their  effect  on  the  general 
health,  and  the  description  of  the  details  of  their  application  belongs  to  general 
medicine. 


370 


GYNECOLOGIC  TREATMENT 


Fig.  471.  Trendelenburg  Posture,  with  the  subject  uncovered  to  show  the  exact  arrangement.  Tlie  elevation 
of  the  hips  is  sufficient  to  cause  the  abdominal  and  pelvic  structures  to  gravitate  toward  the  diaphragm.  (Baldj^ — 
American  Text-book  of  Gynecology.) 

Special  Exercise.  There  is  one  useful  and  simple  procedure  that  is  jDarticularly 
applicable  to  certain  gynecological  patients.  I  refer  to  voluntary  contraction  of 
the  muscles  of  the  abdominal  wall.  This  is  one  of  the  most  effective  measures 
that  can  be  employed  in  the  treatment  of  that  affection  which  is  so  distressing  to 
many  women,  namely,  prominence  of  the  abdomen  from  relaxation  of  the  wall. 
This  is  seen  principally  following  confinement,  the  overstretched  abdominal 
muscles  (overstretched  from  the  pregnancy)  having  never  regained  their  tone. 

The  exercise  consists  in  the  patient  raising  the  head  and  shoulders  while  she 
is  lying  on  her  back.  The  arms  should  be  crossed  over  the  chest  and  the  head 
and  shoulders  raised  by  the  abdominal  muscles  alone.  Once  or  twice  dail}-  the 
patient  goes  through  this  exercise,  raising  the  shoulders  ten  to  twenty  times  at 
each  exercise.  As  the  recti  muscles  l^ecome  strong,  the  movement  may  be  varied 
somewhat  to  the  side  in  order  to  bring  into  action  the  lateral  abdominal  muscles. 


INTERNAL  TREATMENT. 

Internal  treatment  may  1)0  i)i  the  form  of  medicines  or  of  diet  or  of  psycho- 
therapy. 

MEDICINES. 

Internal  medication  affects  pelvic  lesions  principally  in  an  indirect  way — by 
improving  the  cpiality  of  the  blood  supplied  to  the  pelvic  organs,  by  relieving 


INTERNAL  REMEDIES  ;^7J 

congestion  and  bettering  the  pelvic  circulution,  hy  toning  up  the  nervous  system, 
etc.  These  indirect  effects,  however,  iire  often  of  decisive  iinportunce.  The 
formulae  of  the  various  preparations  particularly  useful  in  gynecological  cases  are 
given  in  tiie  Appendix. 

I  wish  here  to  call  attention  to  certain  classes  of  internal  remedies  that  are  often 
indicated  in  the  treatment  of  patients  with  pelvic  disease. 

1.  Uterine  Astringents.  To  this  class  belong  ergot,  stypticin  and  hydrastis. 
Ergot  causes  contraction  of  involuntary  muscular  tissue.  The  uterus  is  com- 
posed principally  of  such  tissue,  consequently  ergot  and  allied  substances  have  a 
marked  tonic  effect  on  the  uterine  wall.  The  relaxed  and  diluted  uterine  blood 
vessels  are  narrowed,  the  chronic  congestion  is  relieved  and  the  tendency  t(> 
inflammatory  infiltration  diminished. 

This  class  of  remedies  is  beneficial  in  all  conditions  of  chronic  uterine  congestion 
and  hemorrhagic  tendency,  except  those  connected  with  pregnancy. 

2.  Laxatives.  It  is  difficult  to  appreciate  the  full  value  of  laxatives  in  the 
treatment  of  patients  with  pelvic  disease  until  the  marked  benefit  due  to  them 
becomes  a  matter  of  personal  observation  through  years  of  experience.  The  in- 
telligent and  systematic  use  of  saline  purgatives  in  acute  inflammatory  conditions 
and  of  the  milder  laxatives  (cascara  sagrada,  etc.)  in  chronic  pelvic  disaeses  is  one 
of  the  greatest  aids  in  restoring  the  organs  to  their  normal  condition,  where  such 
restoration  can  be  accomplished  by  minor  measures,  and  in  preparing  the  struc- 
tures for  successful  operative  work  in  the  cases  where  operation  is  necessary.  A 
constantly  loaded  rectum  and  colon  chokes  the  pelvis  mechanically,  causes 
chronic  pelvic  congestion,  both  liy  direct  pressure  and  l>y  irritation  and  also  In- 
contributing  to  an  atonic  condition  of  the  pelvic  tissues,  and  depresses  the  gen- 
eral health  ])y  auto-intoxication  from  the  intestinal  contents. 

3.  Sedatives.  In  various  conditions  sedatives  are  required,  either  on  account 
of  local  pain  or  because  of  marked  general  nervousness.  The  various  prepara- 
tions in  common  use  are  given  in  the  Appendix.  In  ordinary  pelvic  distress,  con- 
sisting of  a  mixture  of  pain  and  pressure  and  fullness,  the  preparations  containing 
viburnum  prunifolium  usually  give  some  relief.  If  there  is  simply  general  ner- 
vousness and  sleeplessness,  sodium  bromide  is  effective.  If  there  is  associated 
bladder  irritability,  hyoscyamus  in  combination  with  potassium  citrate  or  other 
alkaline  tends  to  lessen  the  vesical  tenesmus.  When  there  is  severe  pain,  stronger 
analgesics  are  required,  for  example,  codeine  in  combination  with  phenacetine, 
and  if  there  is  still  no  relief  it  may  be  necessary  to  give  morphine.  The  lattei-, 
when  given  at  all,  should  be  given  in  such  form  that  the  patient  does  not  know 
what  she  is  taking.  For  that  reason  it  is  preferable  to  give  it  in  a  capsule  in  com- 
bination with  some  indifferent  substance  rather  than  in  the  usual  small  tablets, 
the  contents  of  which  are  at  once  surmised  by  most  patients. 

4.  Tonics.  Tonics  containing  iron  are,  of  course,  indicated  in  anemic  patients, 
and  it  is  usually  advisable  to  give  also  some  one  or  more  of  the  general  tonics, 
such  as  strychnia,  quinine,  arsenic,  etc. 

5.  Organo=therapy.  The  use  of  animal  extracts  or  dessicated  tissue  from  vari- 
ous glands,  has  not  proven  of  as  much  value  in  gynecological  cases  as  some  at  first 


372  GYNECOLOGIC  TREATMENT 

hoped  for.  However,  the  administration  of  dessicated  ovarian  tissue  or  corpus 
luteum  tissue  is  undoubtedly  of  vahie  in  a  large  proportion  of  the  cases  of  de- 
struction of  the  ovaries  by  operation  or  disease.  Also,  in  some  cases  of  excessive 
nervous  disturbance  during  and  immediately  following  the  natural  menopause, 
it  has  given  marked  relief  after  other  measures  failed.  In  order  to  secure  the  de- 
sired effect  the  remedy  must  be  given  continuously  over  a  period  of  several  weeks 
or  months. 

Thyroid  extract  administered  in  cases  of  fibro-myoma,  while  it  has  led  to  some 
remarkable  reported  effects,  is  on  the  whole  probably  not  as  effective  as  ergotin 
when  the  latter  is  given  with  the  same  care  and  persistence. 

6.  Serum  Therapy.  In  various  infective  processes  much  good  may  be  accomplished 
by  the  injection  of  bacterial  products  which  inhibit  the  growth  of  the  corresponding 
bacteria.  The  most  striking  and  certain  effects  are  seen  in  the  cure  of  diphtheria 
by  diphtheria  antitoxin  and  the  prevention  of  tetanus  by  antitetanic  serum. 

Antistreptococcic  serum  in  its  various  modifications  has  proven  beneficial  in 
cases  of  puerperal  infection  and  other  forms  of  streptococcus  infection  and  of  mixed 
(staphylococcus  and  streptococcus)  infection.  In  some  cases  the  effect  is  very 
pronounced,  apparently  saving  the  patient's  life,  while  in  other  cases  there  is  ap- 
parently no  effect. 

It  is  worthy  of  a  thorough  trial  in  severe  cases,  as  explained  under  Acute  Pelvic 
Inflammation  (see  chapter  x.). 

Opsonic  Treatment.  The  object  of  this  treatment  is  to  increase  the  destruction 
of  invading  bacteria  by  the  white  blood-corpuscles  (leucocytes). 

The  power  of  the  leucoc^'tes  to  take  in  and  destroy  bacteria  (phagocytosis)  has 
long  been  known,  through  the  investigation  of  Metchnikoff.  Within  the  last  few 
years  much  additional  information  regarding  phagocytosis  has  been  acquired. 
Various  facts  have  been  brought  out  by  different  investigators,  but  it  is  largely 
through  the  work  of  A.  E.  Wright,  of  England,  that  the  subject  has  been  developed 
to  the  point  where  a  definite  therapeutic  method  has  resulted. 

The  essential  features  of  the  opsonic  theory  and  treatment  may  be  summarized 
briefly  as  follows: 

a.  Leucocytes,  freed  from  the  serum  and  mixed  with  bacteria,  have  no  phago- 
cytic power.  When  blood-serum  is  added  to  the  mixture,  phagocytosis  begins. 
This  difference  is  due  to  some  substance  in  the  serum  that  combines  with  that  par- 
ticular class  of  bacteria,  and  prepares  the  bacteria  for  ingestion  by  the  leucocytes. 
This  is  designated  as  an  "opsonic"  effect  (from  opsone — I  cater  for  or  prepare  food 
for),  and  the  substance  that  thus  prepares  the  bacteria  is  called  an  "opsonin." 

b.  The  opsonic  power  of  a  patient's  blood-serum,  for  the  particular  bacteria 
causing  the  illness,  may  be  definitely  measured  by  bacteriologic  methods.  This  is 
then  compared  with  the  opsonic  power  of  the  blood-serum  of  a  normal  individual 
for  the  same  bacteria.  In  this  way  is  secured  the  "opsonic  index"  (relative  opsonic 
power)  of  the  patient's  blood. 

c.  When  the  opsonic  index  is  low  (poor  resistance  to  the  invading  bacteria), 
it  may  be  increased  by  the  subcutaneous  injection  of  devitalized  cultures  of  the 
infecting  organism.  The  toxic  principle  contained  in  the  bacterial  bodies,  when 
brought  in  contact  with  the  blood-serum,  increases  the  opsonizing  power  of  the 


DIET.     PSYCHO-THERAPY  373 

serum  for  that  particular  kind  of  bacteria.  Thus  the  opsonic  index  of  the  patient's 
blood  may  be  raised  to  normal,  and  then  the  growth  of  the  infecting  micro- 
organism is  checked  and  the  lesion  heals. 

The  injection  of  this  "bacterial  vaccine,"  as  the  devitahzed  culture  is  sometimes 
called,  is  repeated  at  certain  intervals,  depending  on  the  nature  of  the  trouble  and 
the  demonstrated  effect  of  each  injection  on  the  patient's  opsonic  index. 

d.  So  far,  this  treatment  has  proven  most  effective  in  localized  infections,  such  as 
furunculosis,  acne,  persisting  sinuses,  tuberculosis  in  all  forms  and  internal  sup- 
purative lesions.  Striking  results  have  been  reported  in  tubercular  adenitis  and 
tubercular  cystitis — two  lesions  that  often  persist  in  spite  of  every  other  thera- 
peutic measure. 

Some  effec-t  has  been  secured  also  in  tlic^se  diseases  in  whicli  the  bacteria  are  in 
the  blood,  for  example,  in  general  sepsis  from  staphylococci  or  streptococci. 

The  accurate  employment  of  opsonic  therapy  requires  the  services  of  a  skilled 
pathologist  and  a  laboratory.  The  method  is  full  of  promise  in  a  wide  range  of 
chronic  and  acute  infections,  but  it  is  still  in  the  experimental  stage. 

7.  Special  Medication.  In  many  patients  with  pelvic  disease  there  are  com- 
plicating or  associated  disturbances  that  rec}uire  treatment,  such  as  disease  of  the 
stomach,  liver,  lungs,  kidneys,  etc.  Care  should  be  taken  that  such  coincident 
affections  be  not  overlooked  for  they,  as  well  as  the  pelvic  lesion,  must  receive 
proper  treatment  in  order  to  restore  the  patient  to  health. 

DIET. 

A  comprehension  of  the  principles  of  proper  diet  and  an  intelligent  employ- 
ment of  the  same  is  necessary  in  overcoming  malnutrition  and  in  rescueing  pa~ 
tients  from  the  depraved  general  health  occasioned  by  certain  pelvic  diseases. 
In  this  connection,  however,  the  diet  has  to  do  primarily  with  the  general  nutri- 
tion and  only  remotely  with  the  pelvic  lesion.  The  principal  way  in  which  the 
details  of  diet  enter  directly  into  the  treatment  of  pelvic  lesions  is  in  the  after- 
care of  operative  cases,  consequently,  such  details  of  diet  as  I  think  best  to  take 
space  for  will  be  given  in  chapter  xvi. 

PSYCHO-THERAPY. 

Many  nervous  affections  require  psycho-therapy,  such  as  competent  and  dis- 
criminating neurologists  are  using  more  and  more.  This  subject  has  been  care- 
fully investigated  in  recent  years  by  reliable  physiologists  and  clinicians,  and 
methods  of  treatment  have  been  worked  out  which,  in  conjunction  with  neces- 
sary medication  or  operative  measures, will  greatly  has  ten  the  cure  in  many  cases, 
and  will  restore  to  health  some  patients  otherwise  incurable. 

OPERATIONS. 

Careful  anatomical  and  pathological  investigations  have  demonstrated  that 
many  pelvic  lesions  are  of  such  nature  and  so  situated  that  a  cure  can  be  effected 


374  GYNECOLOGIC  TREATMENT 

by  nothing  short  of  operative  treatment,  with  its  direct  handling  of  the  diseased 
tissues  and  extirpation  of  the  hopelessly  damaged. 

In  some  cases  this  is  evident  from  the  very  nature  of  the  lesion,  as  in  the  case  of 
malignant  disease  and  tumors  generally.  On  the  other  hand,  in  many  inflam- 
matory lesions  the  question  as  to  whether  or  not  operative  treatment  will  be  neces- 
sary can  be  answered  decisively  only  after  nature,  with  the  aid  of  minor  meas- 
ures, has  been  given  a  thorough  trial.  The  operative  measures  indicated  in  the 
various  affections  will  be  mentioned  in  the  appropriate  chapters. 


375 


CHAPTER  ly. 

DISEASES  OF  THE  EXTERNAL  GENITALS  AND  VAGINA. 

POINTS  IN  ANATOMY, 

EXTERNAL  GENITALS. 

The  external  genitals  (Figs.  42,  208),  called  also  the  vulva  and  the  pudenda,  in- 
clude the  following  structures: 

Mons  Veneris. 
Labia  Majora. 
Labia  Minora. 
Clitoris. 
Vestibule. 

Vulvo-vaginal  Glands. 
Hymen.    . 

The  mons  veneris  (Figs.  1,  3,  30)  is  simply  a  pad  of  subcutaneous  fat  lying  over 
the  symphysis  pubis.  The  triangular  area  which  it  forms  is  covered  with  hair 
after  puberty.  The  base  of  the  triangle  is  represented  by  a  slight  groove  at  the 
lower  limit  of  the  hypogastric  region,  and  the  lower  portion  is  continuous  ^^•ith 
the  labia  majora.  Examination  of  a  microscopic  section  through  this  region 
shows  the  usual  characteristics  of  skin,  i.  e.,  many  layers  of  squamous  epithelial 
cells  (the  deepest  being  cubical  and  the  most  superficial  being  flattened  and 
horny)  placed  on  loose  connective  tissue,  and  presenting  hairs,  sebaceous  glands 
and  sweat  glands.  A  little  deeper  there  is  much  fat,  which  is  penetrated  and 
held  together  by  fibrous  septa  that  divide  it  into  lodules.  There  are  also  many 
elastic  fibers. 

The  labia  majora  (Figs.  42,  43,  208)  are  two  cutaneous  folds  which 
extend,  one  on  either  side,  around  the  vaginal  opening.  They  are  appar- 
ently continuations  of  the  mons  veneris  and,  passing  backward,  end  by 
joining  the  perineum.  The  external  surface  of  each  labium  majus  presents 
the  ordinary  characteristics  of  integument.  Each  labium  is  limited  exter- 
nally by  the  genito-crural  fold  and  corresponds  to  that  side  of  the  scrotum 
in  the  male.  The  round  ligament,  coming  through  the  inguinal  canal  of 
each  side,  terminates  in  the  upper  part  of  the  labium  majus  of  that  side.  Some- 
times a  distinct  canal  remains  open  for  some  distance  along  the  round  ligament. 
This  is  know^n  as  the  canal  of  Nuck,  and  through  it  a  hernia  may  take  place  into 
the  labium,  constituting  a  labial  hernia.  This  is  known  also  as  a  pudendal  hernia. 
The  hernial  c(mtents  may  be  intestine  or  omentum  or  ovary  or  even  the  uterus. 


376  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

Occasionally  the  canal  of  Nuck  is  shut  off  from  the  peritoneal  cavity,  and  the  sac 
thus  formed  fills  with  fluid,  giving  rise  to  pudendal  hydrocele  or  "  hydrocele  of  the 
canal  of  Nuck."  The  inner  surface  of  each  labium  majus  is  smooth  and  of  a  pink- 
ish color.  It  has  largely  lost  one  of  the  characteristics  of  integument — the  hairs — 
only  a  few  fine  hairs  being  found  here. 

In  children  the  labia  majora  are  very  small  and  the  labia  minora  project  be- 
tween them.  As  puberty  is  approached  the  external  labia  become  larger  and  meet 
in  the  median  line.  At  puberty  they,  in  common  with  the  mons  veneris,  become 
covered  with  hair.  A  little  later  in  life,  particularly  in  married  women,  the  labia 
minora  become  enlarged  so  much  that  they  project  forward,  separating  the  labia 
majora.  In  old  age  the  labia  undergo  marked  diminution  in  size  and  prominence, 
the  shrinking  being  due  largely  to  absorption  of  the  fat. 

Microscopic  examination  of  a  section  of  a  labium  majus  shows  the  same  structures 
found  in  the  mons  veneris,  the  only  difference  being  that  on  the  inner  surface  of 
the  labium  there  are  only  a  few  hairs,  and  they  are  small.  There  are,  however, 
many  sebaceous  glands.  There  are  also,  of  course,  the  arteries,  veins  and  other 
structures  found  in  cutaneous  and  subcutaneous  tissues.  The  connective  tissue  is 
rich  in  elastic  fibers,  and  still  deeper  there  is  the  thick  deposit  of  fat  that  gives  the 
labium  its  prominence.  The  veins  are  numerous  and  large,  and  become  much 
distended  when  there  is  intra-pelvic  pressure,  as  in  pregnancy  or  a  tumor.  Under 
such  circumstances,  a  wound  of  the  labium  may  lead  to  serious  and  even  fatal 
hemorrhage. 

The  labia  minora,  (Figs.  208,  212,  214),  or  nymphae,  are  two  dehcate 
muco-cutaneous  folds  lying  between  the  labia  majora,  one  on  each  side  of 
the  vaginal  opening.  Each  labium  minus  apparently  grows  from,  or  is  a 
secondary  fold  of,  the  upper  and  inner  portion  of  the  labium  majus  of 
that  side.  In  stout  women  the  nymphae  are  normally  concealed  by  the 
labia  majora.  Ordinarily,  particularly  in  married  women,  they  project  slightly, 
l^'requently  they  are  somewhat  enlarged  and  project  half  an  inch  or  more. 
The  enlargement  is  usually  not  exactly  symmetrical,  and  in  some  cases 
it  is  confined  to  one  labium.  In  a  valuable  article  on  these  enlargements  of  the 
labia  minora,  Dickinson  upholds  the  idea  that  whenever  the  enlargement  is  marked 
it  is  proof  of  excessive  irritation  of  the  labium.  It  is  stated  that  among  the  Hot- 
tentots, owing  to  certain  treatment  practiced  in  childhood,  the  labia  minora  often 
becomes  excessively  developed  and  hang  like  a  thick  apron  between  the  thighs 
(Fi"-.  268).  The  labia  minora  begin  just  below  the  anterior  junction  of  the  labia 
majora  as  double  folds  which  pass  above  and  below  the  clitoris  (Fig.  214)  The 
folds  that  join  above  the  clitoris  form  the  prepuce  of  the  same.  The  labium  minus 
of  each  side  then  descends  along  the  inner  side  of  the  labium  majus  and  blends 
with  laljium  majus  about  the  junction  of  the  middle  and  lower  third.  The  posterior 
extremeties  of  the  laljia  minora  are  united  by  a  delicate  fold  which  extends  between 
them-  just  within  the  posterior  margin  of  the  vulvar  orifice,  forming  the  fourchette. 
When  the  labia  are  separated,  the  fourchette  is  made  tense  and  between  it  and  the 
hymen  is  a  small  depression  called,  from  its  boat-like  shape,  the  "fossa  navicularis." 
This  delicate  fourchette  is,  except  in  rare  cases,  torn  at  child-birth,  and  in  some 
cases  is  obliterated   even  Ijy  sexual  intercourse.     It  is  best  seen  in  the  virgin. 


POINTS  IN  ANATOMY  OF  EXTERNAL  GENITALS  377 

There  has  been  much  dispute  as  to  whether  the  inner  surfaces  of  the  labia  minora 
are  covered  by  integument  or  mucous  membrane.  The  covering  presents  some  of 
the  characteristics  of  each.  It  is  a  transional  form  of  covering  and  represents  one 
step  in  the  several  changes  which  take  place  from  the  labia  majora  to  the  external 
surface  of  the  cervix.  The  outer  surfaces  of  the  labia  majora  are  ordinary  integu- 
ment. On  the  inner  surfaces  of  the  same  structures,  the  hairs  are  much  reduced 
in  size  and  number.  On  the  lal)ia  minora,  the  hairs  are  absent,  though  the  sebace- 
ous glands  are  still  present.  On  the  vestibule,  only  a  few  glands  remain  and  tlie 
thinning  of  the  epithelium  is  more  marked.  In  the  vagina,  all  glands  disappear 
(it  being  now  generally  held  that  there  are  no  glands  in  the  normal  vagina)  and 
the  epithelium  becomes  thinner  and  the  papillae  less  marked.  Over  the  vaginal 
portion  of  the  cervix  the  papillae  have  almost  disappeared.  80  there  is  a  gradual 
transition  from  ordinary  integument,  with  a  thick  epithelial  layer  and  hairs  and 
sebaceous  glands  and  sweat  glands  and  marked  papillae,  to  a  thin  epithelial  layer 
without  hairs  or  glands  and  almost  without  papillae.  When  the  vaginal  wall  is 
turned  out  for  a  long  time,  as  in  prolapse,  and  exposed  to  friction  by  the  clothing, 
the  epithelial  layer  becomes  much  thickened,  and  if  the  surface  is  kept  dry  it  be- 
comes horny  like  the  external  integument. 

The  labia  minora  have  many  small  folds,  giving  a  very  uneven  surface.  Ex- 
amination of  a  section  of  a  labium  minus  shows  numerous  epithelial  depressions, 
owing  to  the  much  folded  surface.  The  bands  and  nests  of  epithelial  cells  seen  in 
such  a  section  are  simply  oblique  cuts  of  normal  folds  and  ingrowths.  The  labia 
minora  are  very  rich  in  blood  vessels,  especially  veins,  so  much  so  that  the  struc- 
ture partakes  of  the  nature  of  erectile  tissue.  They  are  also  rich  in  lymphatics 
and  nerves. 

The  clitoris  (Figs.  1,  208,  224,  488)  is  the  analogue  of  the  penis  in  the  male, 
and  is  situated  just  below  the  anterior  junction  of  the  labia  majora.  It  is  a 
small  erectile  organ  richly  supplied  with  blood  and  nerves,  and  is  attached  to 
the  sides  of  the  pubic  arch  by  its  crura.  In  both  the  clitoris  and  the  labia 
minora  there  are  special  nerve  endings.  Examination  of  a  section  of  the 
chtoris  shows  the  erectile  nature  of  the  structure.  During  sextual  excitement 
the  clitoris  fills  with  blood  and  becomes  swollen  and  firmer.  It  is  supposed 
to  be  the  most  sensitive  of  all  the  genital  organs  to  sexual  contact,  and  on  this 
account  excision  of  the  clitoris  (clitoridectomy)  was  proposed  and  carried 
out  for  the  relief  of  disturbances  depending  on  sexual  hyperesthesia,  but  the 
results  were  not  such  as  to  recommend  the  operation,  and  it  is  now  rarely 
practiced. 

The  vestibule  (Figs.  44,  208,  213,  214)  is  an  elliptical  area  situated  between  the 
labia  minora.  The  sides  are  formed  by  the  labia  minora,  the  anterior  end  ex- 
lends  to  the  clitoris,  and  the  posterior  end  is  formed  by  the  junction  of  the  labia 
majora.  Into  this  vestibule  four  canals  open — the  urethra,  the  vagina  and  the 
duct  of  the  vulvo-vaginal  gland  of  each  side.  The  urethral  opening,  the  meatus 
urinarius,  is  situated  just  above  the  vaginal  orifice  (Fig.  214).  In  the  nullipara 
it  is  small  and  round.  In  the  multipara  it  is  larger  and  somewhat  star-shaped, 
and  there  is  often  some  pouting  or  projection  of  the  urethral  mucosa.  This  change 
is  due  to  the  SAvelling   and  distortion   during  labor,    from  which  the   parts  never" 


378 


DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 


return  absolutdr  to  their  former  condition.  The  floor  of  the  vestibule  is  formed 
of  several  layers  of  squamous  epithehum  and  under  this  the  subepithelial  con- 
nective tissue.     There  are  a  few  glands,  some  of  which  at  times  become  enlarged. 


Fig.  472.  Indicating  the  line  of  di\-ision 
of  the  urethra  to  give  the  ^'iew  shown  in  Fig. 
47-3.      (Dudley — Practice  of  Gynecology  ) 


Fig.  474.  Cross-section  of  the  Uretbra, 
showing  the  periurethral  ducts  (Skene's 
glands).  L'.  Urethra.  A.  Periurethral 
Ducts.      (Dudley — Practice  of  Gynecology.') 


Fig.  473.  The  Urethra  di\-ided  so  as  to 
show  the  openings  of  Skene's  glands.  The 
openings  are  situated  just  within  the 
meatus,  one  on  either  side.      (Dudley.) 


The  MEATUS  UEI- 

NARius,  as  well  as 
the  urethra,  is  lined 
with  stratified  squa- 
mous epithehum  on 
a  ba-sis  of  connect- 
ive tissue  rich  in 
cells.  This  comiect- 
ive  tissue  of  the 
meat  u  s  and  the 
urethra  presents 
usually  many  typic- 
al lympl  nodules  of 
microscopic  size. 
Just  within  the 
meatus,  near  the 
posterior  wall,   are 


X^ 


the  openings  of  two  divertula,  one  on  either  side.  They 
are  known  as  Skene's  ducts  or  Skene's  glands.  The}^ 
are  called  also  "periurethral  ducts."  Their  size  and 
shape  and  location  are  shown  in  Figs.  472,  473,  474, 
475.  They  are  important  in  that  gonorrboeal  infection 
may  extend  into  them  and    persist   there  indefinitely.     Just  back  of  the  lining  of 


\ 

Fig.  475.  This  gives  a 
clear  idea  of  the  size  and 
relation  of  the  periurethral 
ducti  (Skene's  gland.s).  The 
floor  of  the  urethra  has  been 
divided  longitudinally,  the 
end  of  tl'.e  urethra  raised 
and  a  probe  introduced  into 
each  of  the  periureth-al 
ducts.  (Skene— i>ise««e3  of 
Women.) 


THE  VULVO-VAGINAL  GLANDS 


379 


the  vestibule  there  are  two  masses  of  veins,  one  on  cither  side  of  the  vaginal 
orifice,  called  the  bulbs  of  the  vestibule  (Fig.  476).  The  bulbi  vestibuli  lie  just 
in  front  of  the  anterior  layer  of  the  triangular  ligament.  They  are  supposed 
to  correspond  to  the  corpus  spongiosum  of  the  male.  In  wounds  of  this  region, 
or  in  operations,  if  these  vascular  bulbs  are  injured  there  is  troublesome  bleeding. 
The  vulvo=vaginal  glands  are  two  glands  situated  beside  the  vaginal  entrance, 
one  on  either  side  (Fig.  49) .  They  correspond  to  Cowper's  glands  in  the  male, 
though  their  relations  to  the  triangular  ligament  is  not  so  clearly  defined,  appar- 
ently varying  some  in  different  cases.     They  lie,  as  a  rule,  behind  the  anterior 


Fig.  476.  The  Veins  of  the  External  Genitals,  including  the  "bulb 
of  the  vestibule,"  on  the  left  side.  V.  Vagina.  M.  Meatus  1.  Left 
venous  "bulb."      {Savage— A7iat07H!j  o/  Pelvic  Organs.) 


layer  of  the  ligament,  and  may  lie  behind  or  in  front  of  the  posterior  layer.  Each 
gland  lies  very  close  to  the  lower  end  of  the  venous  bulb  of  that  side.  The  gland 
is  a  small  reddish  body  about  the  size  of  a  bean,  and  belongs  to  the  racemose 
variety  of  glands.  Its  secretion  is  discharged  through  a  small  duct  which  opens 
just  in  front  of  the  hymen,  about  the  junction  of  the  lower  with  the  middle  third 
of  the  side  of  the  vaginal  orifice.  When  the  gland  is  normal,  this  opening  has  to 
be  looked  for  rather  carefully  to  be  seen.  When  the  gland  has  once  become  in- 
flamed, the  opening  is  easily  seen,  for  it  is  larger  and  is  usually  surrounded  by  a 
small  reddened  area.  The  mucous  secretion  of  the  gland  acts  as  a  simple  lubri- 
cant to  the  parts  and  is  discharged  during  sexual  excitement.  When  inflamed, 
the  gland  is  felt  as  a  hard  tender  mass  beside  the  vaginal  opening  Fig.  (51), 


38'J 


DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 


The  hymen  (Figs.  208,  209)  is  a  circular  or  crescentic  fold  of  mucosa  and  sub- 
mucous connective  tissue,  situated  at  the  vaginal  entrance  and  partially  closing 
the  same  (Fig.  208).  The  shape  of  the  hymen  and  the  opening  in  it  varies  much 
in  different  persons.  Fig.  209  shows  several  forms.  The  crescentic  hymen  and 
the  circular  hymen  are  the  usual  forms.  The  fimbriated  h3^men  has  a  dentated 
or  fringe-like  margin.  The  cribriform  hymen  presents  a  number  of  small  holes. 
In  certain  cases  of  malformation,  the  hymen  is  absent.  In  other  cases  it  closed 
entirely  (imperforate  hymen). 

The  hymen  is  usually  ruptured  at  the  first  sexual  intercourse.  In  some 
cases  "rupture  of  the  hymen"  amounts  to  nothing  more  than  stretching,  with 
slight  abrasion.  In  other  cases  there  is  distinct  tearing,  with  considerable  pain 
and  some  bleeding.  In  rare  cases  there  may  be  persistent  and  even  serious  bleed- 
ing.    In  some  cases  the  hymen  is  so  rigid  or  tender  as  to  prevent  coitus.     Long- 


PL  a~E  v. 


Fig.  477.     The  Arteries  and  Nerve  s  of  the  external  genitals.      (Savage  -Anatomy  of  Pelvic  Organs.) 


continued  sexual  intercourse  stretches  the  hymen  until  it  is  not  at  all  prominent. 
Much  medico-legal  importance  has  been  attached  to  the  condition  of  the  hymen, 
and,  ordinarily,  it  is  a  decided  help  in  determining  whether  or  not  coitus  has  taken 
place.  But  it  is  a  well-established  fact  that  an  intact  hymen  is  not  absolute  proof 
of  virginity,  nor  is  an  apparently  ruptured  or  stretched  hymen  absolute  proof  of 
sexual  intercourse. 

Childbirth  destroys  the  hymen  as  an  intact  ring.  Usually  after  parturition 
there  are  only  irregular  tags  of  tissue  left,  the  result  of  tearing  and  sloughing 
about  the  vaginal  entrance.     These  irregular  tags  of  tissue  surrounding  the  vaginal 


POINTS  IN   ANATOMY  OF  VACINA 


3S1 


orifice  are  known  as  "canmculae  myrtiformes,"  and  result  from  child-birth 
only,  not  from  sexual  intercourse.  Coitus  does  not  usually  destroy  the  hymen, 
l)ut  simply  tears  it  slightly  and  stretches  it. 

The  IJLOOD  SUPPLY  of  the  external  genitals  (Fig.  477)  comes  principally  from 
the  internal  pudic  artery,  one  of  the  terminal  branches  of  the  anterior  trunk  of 
the  internal  iliac. 

The  LYMPHATICS  EMPTY  into  the  inguinal  glands.  Poirier  calls  attention  to  the 
fact  that  the  lymphatics  from  the  clitoris  extend  into  the  deep  pelvic  glands. 
Consequently  in  carcinoma  of  the  clitoris  proper  (not  its  prepuce),  the  glands  within 
the  pelvis  are  soon  involved. 

The  NERVE  SUPPLY  (Fig.  477)  comes  principally  from  branches  of  the  pudic  and 
small    sciatic    nerves.     In  certain    painful  affec- 
tions of  the  external  genitals,  the  pudic  nerve  is 
sometimes  d'vided  or  resected  to  afford  relief. 


VAGINA. 

The  vagina  is  a  musculo-membraneous  canal 
extending  from  the  vulva  to  the  neck  of  the  ute- 
rus, around  which  it  is  attached.  It  lies  between 
the  bladder  and  the  rectum  (Figs.  1  and  3). 

Its  size  and  shape  are  very  variable  and  it  is 
capable  of  gi'eat  distension,  as  is  seen  when  the 
child  passes  through  it  in  labor.  The  length  of 
the  vagina  is  ordinarily  three  to  four  inches  along 
its  anterior  wall,  and  five  to  six  inches  along  its 
posterior  wall.  It  is  constricted  at  its  lower  end, 
where  it  is  partially  closed  by  the  hymen,  and 
becomes  dilated  towards  the  uterine  extremity. 

Normally  the  anterior  and  posterior  vaginal 
walls  lie  in  contact,  and  on  cross-section  the 
cavity  is  represented  by  a  slit  having  somewhat 
the  shape  of  the  letter  H  (Fig.  478).  The  wide 
diameter  of  the  vagina,  some  distance  up  the 
canal,  is  the  transverse  diameter,  but  the  wide 
diameter  of  the  vulvar  cleft  is  the  antero-posterior 
diameter.  Furthermore,  the  anterior  end  of  the 
vagina  lies  so  far  up  in    the  narrow  part  of  the 


Fig.  478.  Cross-section  of  the 
Pelvic  Structures,  showing  the  rela- 
tions of  the  Urethra,  Vagina,  Rectum 
and  Levator  Ani  Muscles.  Notice 
how  the  vaginal  walls  fold  so  that  the 
shape  of  the  cavity  approximates  the 
letter  H.  Ur.  Urethra.  Va.  Vagina. 
R.  Rectum.  L.  Levator  ani 
muscle.  (Savage  -Anatomy  of  Pelvic 
Organs.) 


pubic  arch  (in   patients  where  the  perineum  has 

not  been  damaged)  that  there  is  not  much  room  laterally.  Consequently  in 
introducing  the  speculum,  the  preferable  way  is  to  introduce  one  finger  into  the 
vaginal  opening  and  press  the  perineum  well  back  (Fig.  92),  so  that  the  vaginal 
opening  is  stretched  antero-posteriorly  and  made  to  correspond  in  a  measure 
with  the  vulvar .  cleft,  and  then  introduce  the  speculum  obliquely  as  shown 
in  Figs.  92  and  93.  When  the  speculum  is  well  past  the  entrance,  so  that  it  may 
be  used  to  depress  the  perineum,  it  is  then  turned  with  its  width  in  the  transverse 
diameter  of  the  vaginal  canal  (Fig.  94)  and  introduced   all   the  way.     From  my 


382  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

experience,  I  think  this  is  decidedly  the  preferable  way  of  introducing  the  specu- 
lum, when  the  perineum  is  intact  -and  resisting.  I  consider  erroneous  the  state- 
ment by  some  authorities  that  the  speculum  should  be  introduced  with  the  wide 
diameter  transversely,  "  because  the  wide  diameter  of  the  vaginal  canal  is  trans- 
verse." The  speculum  must  first  pass  the  vulvar  cleft  and  vaginal  entrance, 
and  we  must  deal  with  the  conditions  found  there  before  accommodating  the 
speculum  to  the  wide  diameter  of  the  canal  proper.  Of  course,  in  a  large  propor- 
tion of  cases  the  perineum  is  lax  from  damage  and  the  primary  anatomical  rela- 
tions are  destroyed,  and  the  speculum  may  be  introduced  in  any  way  without 
resistence. 

Relations.  Fig.  1  shows  the  angle  which  the  axis  of  the  uterus  normally  bears 
to  the  axis  of  the  vagina.  The  upper  end  of  the  vagina  surrounds  the  lower  end 
of  the  uterus.  That  portion  of  the  cervix  uteri  projecting  into  the  vagina  is  known 
as  the  vaginal  portion  (portio  vaginalis).  The  attachment  of  the  vagina  extends 
higher  on  the  posterior  wall  of  the  cervix  than  on  the  anterior.  The  vaginal 
mucosa  is  continued  on  the  cervix  as  far  as  the  external  os. 

The  upper  end  of  the  vagina  is  termed  the  "vaginal  vault."  The  term  "fornix" 
is  also  much  used,  the  anterior  fornix  being  that  portion  of  the  vault  in  front  of  the 
cervix,  and  the  posterior  fornix  being  that  portion  lying  behind  the  cervix,  and  the 
right  and  left  lateral  fornix  lying  to  the  right  and  left  respectively.  With  the 
for  uterus  in  normal  position,  the  posterior  fornix  is  much  deeper  than  the  anterior, 
for  the  vaginal  wall  is  attached  higher  on  the  posterior  surface  of  the  cervix  than 
on  the  anterior. 

The  vagina  is  surrounded  by  important  structures.  The  anterior  wall  is  in  con- 
tact with  the  urethra  and  the  base  of  the  bladder  (Fig.  1).  The  vaginal  wall  and 
bladder  wall  and  the  tissue  lying  between  them,  constitute  the  vesico-vaginal  sep- 
tum. The  posterior  wall  for  the  lower  three-fourths  of  its  extent  is  attached  to 
the  anterior  wall  of  the  rectum,  except  the  very  lowest  portion,  which  is  separated 
from  the  rectal  wall  by  the  perineum.  The  vaginal  and  rectal  walls  and  the 
tissue  lying  between  them,  constitute  the  recto-vaginal  septum.  The  upper  fourth 
of  the  posterior  wall  is  separated  from  the  rectum  by  the  recto-uterine  pouch 
of  peritoneum,  known  as  the  "cul-de-sac  of  Douglas"  (Figs.  3  and  4).  The  sides 
of  the  vagina  give  attachment  to  fibers  from  the  levator  ani  muscles  and  the 
recto-vesical  fascia. 

Structure.  The  wall  of  the  vagina  presents  three  layers — an  external  connective 
tissue  layer,  a  middle  muscular  layer  and  an  inner  mucous  layer.  The  connective 
TISSUE  layer  serves  to  attach  the  vagina  to  the  adjacent  organs.  It  contains  the 
external  plexus  of  veins,  and  is  composed  of  connective  tissue  filled  with  lymphatics 
and  blood  vessels,  the  veins  being  especially  numerous.  The  attachment  of  the 
vagina  anteriorly  is  firm  in  the  lower  third,  where  it  is  attached  to  the  in-ethra. 
It  is  more  loosely  attached  to  the  bladder  in  the  middle  and  upper  third,  particu- 
larly the  latter,  and  is  easily  separated  in  operating. 

The  MUSCULAR  LAYER  contains  involuntary  muscle  fibers  arranged  in  bundles 
without  distinct  strata.  Some  of  the  bundles  are  longitudinal,  some  transverse 
and  some  oblique.  The  muscular  layer  is  thicker  at  the  lower  than  at  the  upper 
end. 


THE  VAGINAL  MUCOSA  'SfiS 

The  MUCOUS  layer,  or  the  lining  of  tlie  vagina,  is  apparently  a  modified  epi- 
dermis. It  presents  on  the  surface  the  usual  layer  of  squamous  epithelium  several 
cells  thick  and,  beneath  this,  connective  tissue  rich  in  cells.  The  glands  have  all 
disappeared  and  the  papillae  are  much  smaller  than  are  encountered  in  the  ex- 
ternal genitals.  The  vagina  normally  contains  no  glands.  The  secretion  found  in 
the  vagina  comes  from  the  cervix  and  the  endometrium,  principally  the  former. 
The  vaginal  walls  are  kept  constantly  moist  with  the  secretion,  and  consequently 
the  epithelium  desquamates  before  it  advances  so  far  in  the  process  of  cornification 
as  is  seen  in  integument.  In  cases  of  prolapse,  where  the  vagina  is  turned  outside 
the  vulva  and  is  subjected  to  fridtion  of  the  clothing  and  is  kept  dry  by  contact 
with  the  same,  it  becomes  more  like  ordinary  epidermis  and  shows  well-marked 
keratin  changes.  The  mucosa  (epithelium  and  connective  tissue  immediately 
under  it)  is  attached  to  the  muscular  coat  by  a  submucous  layer  of  loose  connective 
tissue  which  is  very  rich  in  interlacing  veins,  about  some  of  which  are  bundles  of 
muscular  fibres,  forming  a  kind  of  cavernous  tissue. 

The  vaginal  mucosa  is  thrown  into  numerous  large  folds  called  "rugae." 
Extending  longitudinally  along  both  the  anterior  and  the  posterior  wall  of  the 
vagina  is  a  prominent  ridge,  best  marked  in  the  virgin.  These  ridges  are  known 
as  the  "columns"  of  the  vagina,  and  from  them  the  rugae  extend  laterally.  The 
columns  and  rugae  become  more  or  less  obliterated  by  child-birth,  so  that  in  many 
multipara  the  vaginal  walls  are  almost  smooth. 

Vessels  and  Nerves.  The  blood  supply  of  the  vagina  comes  from  the  anterior 
trunk  of  the  internal  iliac,  through  the  vaginal,  uterine,  middle  hemorrhoidal  and 
internal  pudic  arteries.  These  anastamose  freely  in  the  vaginal  wall.  The  veins 
of  the  vagina  are  arranged  principally  in  two  plexuses  that  form  complete  vasculai* 
sheaths  around  the  canal.  One  plexus  is  external  to  the  muscular  layer,  while 
the  other  lies  just  beneath  the  mucosa.  These  veins  form  an  intricate  network 
and  communicate  freely  with  the  plexuses  of  the  other  organs  and  with  the 
plexuses  of  the  broad  ligament. 

The  lymphatics  from  the  lower  third  of  the  vagina,  it  is  generally  held,  join  those 
from  the  external  genitals  and  empty  into  the  inguinal  glands.  But  Poirier,  who 
has  made  a  special  study  of  the  subject,  claims  that  all  the  lymphatics  of  the  va- 
gina empty  into  the  pelvic  glands  and  that  when  an  injection  of  the  vaginal  lymph- 
atics is  made,  even  just  within  the  hymen,  no  injection  material  passes  to  the 
inguinal  glands  except  through  some  anastomosing  channels.  The  lymphatics 
from  the  middle  third  of  the  vagina  empty  into  the  hypogastric  glands.  Those 
from  the  upper  third  join  with  the  lymphatics  of  the  cervix  uteri  and  pass  to  the 
iliac  glands. 

The  NEEVE  SUPPLY  of  the  vagina  comes  from  pelvic  plexus  of  each  side. 


Jiy4  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

CLASSIFICATION  OF  DISEASES 

Of  The  External  Genitals  and  Vagina. 

Gonorrhoea. 

Other  Inflammatory  Diseases  of  the  Vulva — Simple  Vulvitis,  Folli- 
cular Vulvitis,  Erysipelas,  Cellulitis,  Gangrene,  Diphtheria,  Eczema, 
Intertrigo,  Herpes,  Prurigo,  Parasitic  Diseases. 

Other  Inflammatory  Diseases  of  the  Vagina — Simple  Vaginitis,  Para- 
sitic Vaginitis,  Diphtheritic  Vaginitis,  Emphysematous  Vaginitis,  Ad- 
hesive Vaginitis. 

Ulcers  of  Vulva  and  Vagina — Simple  Ulcer,  Chancroid,  Syphilis,  Tu- 
berculosis, Malignant  Disease,  Ulcus  Rodens  Vulvae. 

Urethral  Affections — Urethritis,  Peri-urethral  Abscess,  Prolapse  o: 
Urethral  Mucosa,  Urethral  Caruncle. 

Vulvo-vaginal  Gland  Affections — Inflammation,  Abscess,  Sinus, 
Cyst. 

Non-malignant  Growths  and  Swellings — Condylomata,  Cysts,  Fibro- 
mata, Lipomata,  Stasis  Hypertrophy,  Elephantiasis,  Pudendal  Hernia, 
Pudendal  Hydrocele,  Hematoma,  Varicose  Veins. 

Injuries  of  Vulva  and  Vagina. 

Miscellaneous  Affections — Kraurosis  Vulvae,  Pruritis  Vulvae,  Hyper- 
esthesia of  Vaginal  Entrance,  Adhesions  of  Prepuce  and  Labia. 

(The  more  pronounced  Malformations  are  considered  in  chapter  xiii.) 

GONORRHOEA. 

Gonorrhoea  is  inflammation  of  the  genital  organs  produced  by  the  gonococcus. 
The  term,  when  not  qualified,  is  understood  to  mean  gonorrhoeal  inflammation  of 
the  vulva,  vagina  and  urethra,  i.  e.,  gonorrhoeal  vulvitis,  vaginitis  and  urethritis. 
If  the  process  extends  into  the  uterus  or  Fallopian  tubes  or  bladder,  it  causes  com- 
plications known  respectively  as  gonorrhoeal  endometritis,  gonorrhoeal  salpingitis 
and  gonorrhoeal  cystitis.  Gonorrhoea  is  sometimes  referred  to  as  "specific" 
vaginitis  or  vulvitis  or  urethritis. 

ETIOLOGY. 

Gonorrhoea  is  caused  by  contact  of  the  affected  organs  with  a  gonorrhoeal  dis- 
charge, usually  in  sexual  intercourse.  The  infecting  germ  (the  gonococcus)  is  a 
diplococcus,  easily  stained,  and  is  found  in  large  numbers  in  the  pus  cells  of  all 
acute  gonorrhoeal  discharges  (Fig.  479).     In  chronic  gonorrhoeal  discharges  it  is 


GONORRHOEA  3g5 

not  found  so  abundantly,  in  fact,  In  some  cases  it  is  so  scarce  as  to  be  very  hard  to 
find,  and  may  even  disappear  entirely  for  a  time. 

All  discharges  containing  the  gonococcus  are  capable  of  causing  gonorrhoea. 
The  slight  urethral  discharge  from  a  chronic  deep  urethritis  or  from  a  stricture, 
pei-sisting  months  or  years  after  an  attack  of  gonorrhoea  in  the  male,  is  very  liable 
to  cause  gonorrhoea  when  brought  in  contact  with  virgin  soil. 

A  sad  exemplification  of  this  fact  is  seen  in  the  many  instances  in  which  a  bride 
is  infected  by  her  husband,  who  had  gonorrhoea  years  before  but  supposed  himself 
well.  The  consequence  of  such  infection  is  that,  instead  of  a  healthy,  happy  woman 
with  sons  and  daughters,  the  wife  becomes  a  confirmed  invalid  in  a  childless  home. 
This  danger  is  not  sufficiently  appreciated  by  men  generally — in  fact,  the  man 
usually  does  not  know  the  danger  until  too  late.  The  responsibiUty  of  physicians 
in  this  matter  is  gi-eat,  for  the  physician  must  decide  when  a  man  who  has  had 
gonorrhoea  may  safely  marry. 

The  report  of  the  special  committee  appointed  by  the  American  Medical  Associ- 
ation to  consider  this  question,  is  worthy  of  study  (Journal  A.  M.  A.,  March  30, 
1901).  The  committee  was  appointed  to  determine  whether  a  man  who  has  had 
gonorrhoea  may  ever  safely  marry,  and,  if  so,  when?  Careful  inquiries  were  made 
and  replies  were  received  from  the  leading  teachers  of  genito-urinary  surgery  in 
this  country  and  in  Europe. 

Among  the  questions  asked  were  the  follovsdng,  concerning  of  course  gonorrhoea 
in  the  male: 

1.  Is  gonorrhoea  curable — so  curable  that  the  physician  can  confidently  say  to 
his  patient,  "You  may  marry  now.     You  run  no  risk  of  infecting  your  wife"? 

2.  Upon  what  tests  do  you  rely  in  order  to  determine  positively  whether  the 
patient  is  wholly  free  from  the  gonococcus  and  is  not  infectious? 

3.  What  period  of  time  should  elapse  after  the  disappearance  of  the  last  evi- 
dence of  the  gonococcus  before  the  patient  should  be  permitted  to  marry? 

The  following,  I  think,  fairly  represents  the  concensus  of  opinion  of  the  author- 
ities quoted  in  that  report: 

1.  Curability.     Gonorrhoea  is  curable  with  the  following  exceptions: 

a.  Gonorrhoea  is  not  curable  in  the  sense  that  the  physician  can  guarantee  that 
no  infection  will  result  therefrom,  but  so  that  in  good  conscience  he  can  give  an 
assurance  that,  in  all  human  probability,  no  infection  will  result. 

b.  There  are  a  few  cases  (estimated  by  one  authority  as  about  3%)  which,  on 
account  of  an  especially  deep-seated  lesion  or  serious  complications,  are  incurable. 
These  patients  can  never  safely  marry. 

2.  Determination  of  Cure.  All  agree  that  the  examinations  must  be 
thorough  and  repeated,  and  that  only  on  the  basis  of  repeated  negative  examina- 
tions, conducted  over  a  considerable  period  of  time,  should  the  conclusion  be 
reached  that  the  patient  is  no  longer  infectious. 

The  following  points  are  insisted  on; 

a.  Absence  of  the  gonococcus. 

b.  Absence  of  pus  germs. 

c.  Absence  of  pus  cells. 


386  DISEASES  OF  EXTERNAL  GE.VITALS  AND  VAGINA 

It  is  pointed  out  that  the  ordinary  pus  germs  may  cause  trouble,  and  that  eases 
have  occurred  in  which  the  husband  carried  to  the  wife  a  pj'ogenic  infection  caus- 
ing serious  pelvic  disease,  though  the  gonococcus  had  entirely  disappeared  and  did 
not  reappear  in  either  husband  or  wife. 

3.  Time  Limit.  The  period  of  time  which  should  elapse  after  the  disappear- 
ance of  the  last  evidence  of  the  gonococcus  before  the  patient  should  be  permitted 
to  marry,  is  given  by  several  authorities  as  one  year.  Others  state  three  months 
to  a  year,  depending  on  the  circumstances  of  the  case. 

Though  the  usual  cause  of  gonorrhoea  is  sexual  contact  with  an  infected  per- 
son, it  maj^  exceptionally  be  caused  by  other  means,  as  by  contact  with  an  infected 
towel  or  douche-nozzle  or  chamber  utensil  or  closet-seat. 

PATHOLOGY. 

There  is  acute  inflammation  of  the  vulva  and  usually  of  the  vagina  and  of  the 
urethral  mucous  membrane  near  the  meatus. 

There  are  present  the  cardinal  signs  of  inflammation — heat,  pain,  redness  and 
swelling.  There  is  at  first  abnormal  dryness  of  the  parts,  then  a  slight  secretion, 
which  rapidly  increases  in  a  day  or  two,  and  when  the  inflammation  is  well 
established  it  becomes  a  free  yellow  discharge,  causing  much  irritation  of  the 
adjacent  surfaces.  There  is  the  ordinary  serous  and  cellular  infiltration  into  the 
involved  areas.  The  most  superficial  layers  of  epithelium  are  thrown  off  and  the 
gonococci  penetrate  the  underl}dng  tissues  to  a  gi-eater  or  less  extent,  depending 
on  the  severity  and  duration  of  the  inflammation.  There  may  be,  later,  a  mixed 
infection,  one  or  more  of  the  ordinary  pus  germs  being  found  with  the  gonococcus. 

The  process  may  affect  only  the  vulva  or  the  upper  part  of  the  vagina.  Some 
authorities  state  that  this  is  the  rule,  but  in  my  experience  such  limitation  is 
exceptional  in  adults  Tvdth  primary  infection,  the  first  examination  usually  show- 
ing involvement  of  practically  all  of  the  vaginal  wall. 

The  gonorrhoeal  inflammation  is  very  liable  to  extend  into  one  or  both  of  the 
vulvo-vaginal  glands  or  into  the  cervix  uteri,  and  to  remain  active  there  after  all 
other  symptoms  have  disappeared. 

In  the  gonorrhoea  of  children  the  process  is  usually  limited  to  the  vulva  and 
urethra,  for  the  reason  that  penetration  of  the  vagina  by  the  infection  carrier  rarely 
takes  place. 

In  reinfection  in  adults,  the  process  is  comparatively  mild  and  is  usually  limited 
to  certain  areas,  for  example  the  vulva  or  urethra  or  upper  part  of  the  vagina. 

The  gonococcus  seems  to  thrive  best  in  the  urethral  m.ucous  membrane,  and  it 
may  penetrate  into  Skene's  glands  and  remain  there  indefinitely. 

SYMPTOMS. 

Within  a  few  days  after  suspicious  coitus  the  patient  complains  of  slight  irrita- 
tion about  the  genitals.  The  parts  feel  dry  and  uncomfortable,  and  there  may  be 
a  slight  burning  seasation.  The  feeling  of  discomfort  increases  and  a  discharge 
appears.  About  the  same  time  or  a  little  later,  there  is  noticed  a  smarting  or 
burning  on  urination  and  increased  frequency  of  urination.     Within  two  or  three 


DIAGNOSIS  (.!•   liONORRHOKA  3g7 

days  of  the  beginning  of  the  troiil^le  the  discharge  is  profuse  and  the  signs  of  irri- 
tation (burning  and  itching  and  frequent  painful  urination)  are  marked. 

On  inspection,  the  structures  immediately  surrounding  the  vaginal  orifice  are 
found  reddened  and  painful  on  pressure.  There  is  a  yellow  discharge  from  the 
vagina  and  frequently  some  discharge  from  the  urethra.  Acute  gonorrhoeal 
discharge  leaves  a  yellow  stain  where  it  dries  on  the  clothing. 

On  digital  examination,  the  vaginal  walls  are  found  rough  and  hot  and  tender. 
Pressure  on  the  anterior  vaginal  wall  directed  from  the  upper  end  of  the  urethra  to 
the  meatus,  will  bring  to  view  one  or  more  drops  of  urethral  pus  (Figs.  46,  47) .  If 
the  case  has  passed  beyond  the  acute  stage,  the  pain  and  discomfort  are  not  so 
marked,  but  the  discharge,  more  or  less  profuse,  is  still  present, 

DIAGNOSIS. 

Gonorrhoea  must  be  distinguished  from  vulvitis  and  vaginitis  due  to  various 
other  causes. 

The  distinguishing  characteristics  of  gonorrhoea  are  as  follows: 

1.  Rapidity  of  development  and  severity  of  symptoms.  The  inflammation  with 
its  accompanying  symptoms  usually  reaches  its  height  within  the  first  week  and 
then  begins  to  subside.  As  a  rule  with  but  few  exceptioas,  other  infiammations 
of  the  vagina  are  not  so  severe  nor  the  discharge  so  profuse.  Occasionally  there 
occur  instances  of  very  mild  gonorrhoeal  infection.  This  mild  reaction  to  the 
the  gonococcus  is  found  almost  exclusively  in  tissues  that  have  suffered  previous 
gonorrlioeal  infection  or  that  have  become  somewhat  hardened  by  frequent  child- 
bearing. 

2.  Involvment  of  the  urethra  and  vulvo=vaginal  glands  or  ducts.  These  exten- 
sions of  the  inflammatory  process  are  rare  in  ordinary  pus  infections.  In  fact  the 
involvement  of  the  meatus  and  of  the  openings  of  the  ducts  of  the  vulvo-vaginal 
glands  is  so  constant  in  gonorrhoea  and  so  infrequent  in  other  forms  of  inflamma- 
tion, that  some  authors  hold  that  it  can  be  determined  whether  or  not  a  patient 
has  ever  had  gonorrhoea  by  determining  the  presence  or  absence  of  evidences  of 
previous  inflammation  of  the  structures  just  mentioned.  Such  evidences  are 
a  reddish  margin  around  the  meatus,  with  rolling  outward  and  chronic  congestion 
of  the  urethral  mucous  membrane,  and  a  bright  red  spot  marking  the  orifice  of  the 
vulvo-vaginal  gland  of  each  side  (so  called  "gonorrhoeal  maculae"),  and  some- 
times pressure  on  the  gland  will  cause  pus  to  appear  at  the  opening  of  the 
duct  (Fig.  50)  Though  such  inflammation  is  usually  caused  by  gonorrhoea,  it 
occasionally  occur  from  other  causes,  and  consequently  is  not  an  absolute  in^ 
dication  of  previous  gonorrhoea. 

3.  No  other  apparent  cause  for  the  inflammation.  Vaginitis  other  than  gonor- 
rhoeal presents  some  cause  for  its  existence,  for  example,  pus  infection  following 
labor  or  abortion,  the  use  of  an  infected  douche-nozzle  or  the  development 
of  that  local  nutritive  change  which  causes  senile  vaginitis. 

4.  Development  within  a  few  days  after  sexual  intercourse.  Considerable  pain 
from  slight  traumatism  and  some  bladder  disturbance  may  follow  coitus,  particu- 
larly in  the  newly  married,  but  such  cases  do  not  present  the  profuse  yellow  dis- 


388  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

charge  of  gonon-hoea.  In  the  case  of  a  married  woman,  be  careful  not  to  question 
her  in  such  a  waj^  as  to  associate  the  trouble  with  coitus,  as  it  may  arouse  her 
suspicion  and  cause  trouble  in  the  family. 

5.  Presence  of  the  gonococcus.  The  presence  of  the  gonococcus  is  determined 
by  microscopic  examination  of  the  pus  from  the  infected  areas.  With  the  tip 
of  the  applicator  take  a  small  amount  of  the  urethral  discharge  and  spread  it  in 
a  thin  film  on  two  glass  slides,  or  on  cover-glasses  if  preferred.  If  using  cover- 
glasses,  spread  four  or  five  with  the  urethral  pus,  for  some  may  get  broken.  If 
desired,  specimens  of  pus  may  be  taken  from  other  locaUties  also,  for  example, 
from  the  ducts  of  the  vulvo- vaginal  glands  or  from  the  upper  or  lower  part  of  the 
vagina  or  from  the  cer^'ix,  the  specimens  from  the  different  localities  being  desig- 
nated a.s  described  on  page  35. 

Staining  the  Gonococcus. 

One  of  the  spread  preparations,  on  a  cover-glass  or  a  glass  slide,  is  stained  by  a 
methylene-blue  solution.  If  the  microscopic  findings,  taken  in  connection  with  the 
history  of  the  case  and  the  physical  signs,  make  the  diagnosis  clear,  no  further 
etaining  is  necessary.  If  it  is  doubtful,  then  another  prepared  cover-glass  or 
shde  is  subjected  to  Gram's  decolorization  method. 

The  details  of  staining  are  practically  the  same  whether  the  preparation  be  on  a 
glass  shde  or  on  a  cover-glass.  The  cover-glass  is  held  in  a  forceps,  while  the  slide 
is  held  in  the  fingers. 

We  will  suppose  the  preparations  are  on  cover-gla.sses  and  were  made  some 
minut-es  ago  and  laid  aside,  while  the  other  steps  in  the  diagnosis  and  treatment 
were  carried  out  and  the  patient  dismissed. 

The  cover-glasses  are  now  dry  and  ready  to  be  stained. 

1.  Staining  with  methylene=blue  solution.  The  steps  in  this  process  are  as  fol- 
lows: 

a.  With  the  cover-glass  forceps  pick  up  one  of  the  prepared  cover-glasses,  charged 
side  up,  and  pass  it,  rather  slowly,  three  or  four  times  through  the  flame  of  the 
Bunsen  burner  or  alcohol  lamp.  This  "fixes"  the  specimen  to  the  glass,  so  it  is 
not  washed  off  in  the  subsequent  manipulations. 

b.  Flood  the  prepared  surface  of  the  cover-glass,  held  in  the  forceps,  with  a  few 
drops  of  Loffler's  alkaline  methylene-blue  solution  or  1%  aqueous  solution  (fresh) 
of  methjdene-blue.  Hold  the  cover-glass  high  above  the  flame,  so  that  it  steams 
some  but  does  not  boil,  for  about  half  a  minute.     This  stains  the  specimen. 

c.  Then  wash  off  the  excess  of  stain  with  clear  water. 

d.  Then  lay  the  cover-glass,  charged  surface  down,  on  a  clean  glass  slide  and 
remove  the  excess- of  water  and  dry  the  upper  surface  of  the  cover-glass  with  blot- 
ting paper. 

e.  Put  on  a  drop  of  cedar  oil  and  examine  with  the  oil-immersion  leiLS.  The 
microscope  for  this  work  should  be  provided  with  a  1-12  inch  oil-immersion  lens 
and  an  Abbe  condenser.  The  cover-glasses  should  be  very  thin  (No.  1).  The 
No.  2  cover-gla.sses  do  not  break  so  easily,  but  every  once  in  a  while  there  is  one 
that  is  too  thick  for  the  use  of  the  oil-immersion  lens.     The  cover-glasses  may  be 


STAINING  THE  GONOCOCCUS 


389 


kept  in  alcohol  in  a  flat  wide-mouthed  bottle,  from  which  they  are  removed  and 
dried  (cleaned)  as  needed. 

In  the  methylene-blue  specimen,  the  nucleus  of  each  pus  cell  is  stained  a  light 
blue.  These  nuclei  are  very  irregular  in  shape  and  some  of  them  are  broken  into 
two  or  more  parts.  They  form  the  prominent  light  blue  masses  which  largely 
occupy  the  field.  The  protoplasm,  or  body,  or  each  cell  is  stained  only  very  faintly, 
so  faintly  that  it  is  ill-defined  and  hardly  noticeable.  All  bacteria  taking  the  stain, 
including  the  gonococci,  are  stained  a  very  dark  blue  (almost  black)  and  contrast 
well  with  the  light  blue  nuclear  masses. 

In  vaginal  specimens,  the  field  is  so  filled  with  bacteria  of  various  shapes  and 
sizes,  that  the  gonococci  are  more  or  less  obscured.  In  urethral  specimens,  how- 
ever, there  are  as  a  rule  but  few  other  bacteria  and  consequently  the  gonococci  are 
more  easily  found. 


Fig.  479.  Specimen  of  pus  from  a  case  of  Gonorrhoea, 
stained  with  Methylene-blue.  This  field  contains  two 
gonococcus-colonies,  each  within  a  pus  cell.  Only  the 
nuclei  of  the  pus  cells  are  seen.  The  lower  colony  has  the 
circular  outline  of  the  cell  containing  it.  (Kolle  and  Was- 
sermsLQu—Handbuch  der  Pathogenen  MiJcroorganismen) . 


si 


Fig.  480.  Indicating  the  Shape  of 
the  diplococcus  of  gonorrhoea  (Gono- 
coccus).  (Byford — Manual  of  Gynec- 
ology.) 


In  acute  gonorrhoea  the  gonococci  are  seen  lying  in  colonies  in  the  pus  cells 
(Fig.  479)  with  a  few  scattered  between  the  cells.  They  occur  as  diplococci,  the 
two  together  having  about  the  shape  of  two  coffee  grains  with  their  flat  surfaces 
turned  toward  each  other  and  slightly  separated  (Fig.  480).  They  are  spoken  of 
as  "biscuit-shaped"  or  "roll-shaped." 

The  occurrence  of  the  gonococci  in  small  detached  groups  (Fig.  479),  is  a  striking 
feature  in  a  good  specimen.  The  little  colonies  occur  inside  the  pus  cells,  the  pus  cell 
being  recognized  by  the  well-marked  blue  nucleus  of  irregular  shape.  The  proto- 
plasm is  hardly  visible,  but  it  is  known  that  the  gonococci  must  be  within  the  cell  be- 
cause they  are  gi-ouped  so  closely  about  the  nucleus.  In  some  cases  the  cell  has 
broken  down  and  the  colony  has  outgi'own  its  dimensions.     But  the  colony  is  still 


390  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

close  to  the  disintegrating  nucleus,  and  the  outlines  of  the  colony  have  the  general  cir- 
cular shape  of  the  cell  which  recently  housed  it.  At  some  other  point  a  cell  has  ad- 
vanced still  further  in  the  process  of  disintegration  and  has  largely  disappeared  and 
the  colony  of  gonococci  has  broken  up,  the  individual  gonococci  being  scattered 
through  the  space  between  the  other  cells.  Only  comparatively  few  of  the  pus  cells 
show  a  gonococcus  colony.  In  some  cases  several  microscopic  fields,  filled  with  pus 
cells,  may  be  looked  over  without  seeing  a  gonococcus,  and  then  a  pus  cell  with  a 
fine  colony  is  encountered. 
The  distinguishing  characteristics  of  the  gonococci  are: 

a.  Roll-shaped  diplococci,  occurring  in  detached  groups  or  colonies. 

b.  Presence  within  the  pus  cells. 

c.  Decolorization  by  Gram's  method  of  staining. 


Fig.  481.  Specimen  of  pus  from  a  case  of  Gonorrhoea, 
stained  by  Grain's  Decolorization  method.  As  explained  on 
the  next  page,  the  gonococcus  is  a  "Gram-negative"  bacte- 
rium, and  hence  is  decolorized  by  this  method  and  does  not 
appear  in  a  specimen  thus  prepared.  {Photomicrograph  by 
Dr.  C.  Fisch.) 

In  acute  cases  it  is  rarely  necessary  to  stain  by  Gram's  method.  If  the  patient 
gives  the  clinical  history  and  evidences  of  acute  or  subacute  gonorrhoea,  and  the 
microscopic  examination  of  the  discharge  shows  a  diplococcus  within  the  pus  cells, 
presenting  the  form  of  the  gonococcus  and  occurring  in  large  numl^ers  and  arranged 
in  groups  and  without  other  bacteria  to  account  for  the  discharge,  that  patient  has 
gonorrhoea  beyond- a  reasonable  doubt. 

If  the  patient  presents  the  clinical  evidences  of  acute  gonorrhoea  and  micro- 
scopic examination  of  the  discharge  shows  the  a])scncc  of  a  diplococcus,  such  as 
above  described,  the  strong  probability  is  that  the  trouble  is  not  gonorrhoeal, 
tiiough  it  is  well  to  make  more  than  one  examination  ((lifr(M(uit  d;iys)  l)efore  decid- 
ing adversely  to  the  ordinary  clinical  evidences. 

In  the  acute  inflammations  that  arc  not  gonorrhoeal,  there  is  usually  found  some 


DECOLORIZATION  BY  GUAM'S   METHOD  391 

other  germ,  of  sufficient  virulence  and  in  sufficient  numbers,  to  account  for  the 
discharge.  If  there  is  any  question  as  to  the  identity  of  the  supposed  gcjuoccn-ci, 
preparations  should  he  subjected  to  drain's  stain. 

2.  Decolorization  by  Gram's  method.  The  feature  of  Gram's  staining  method 
is  that  certain  bacteria  arc  stained  by  it  (Gram-positive  bacteria)  while  others  are 
decolorized  and  hence  do  not  appear  in  the  specimen  (Gram-negative  bacteria) 
The  gonococcus  is  "  Gram-negative,"  hence  it  is  not  seen  in  a  specimen  so  prepared. 
The  value  of  this  lies  in  the  fact  that  certain  other  bacteria  resembling  the  gono- 
coccus closely  as  to  form,  are  Gram-positive  and  hence  appear  deeply-stained  in 
a  Gram  preparation. 

Consequently  in  an  acute  case,  if,  after  examining  a  specimen  of  pus  stained 
with  the  methylene-blue  solution,  and  finding  bacteria  of  the  form  and  distribu- 
tion of  the  gonococcus  (Fig.  479),  another  specimen  of  the  same  pus  is  stained  by 
Gram's  method  and  these  bacteria  do  not  appear  (Fig.  481),  the  bacteiia  in 
question  are  certainly  gonococci. 

The  regular  Gram  method  is  quite  long  and  troublesome.  Dr.  E.  F.  Tiede- 
mann,  Professor  of  Pathology  in  Washington  University,  has  devised  a  convenient 
modification  of  it.     I  quote  the  details  from  his  published  report. 

"Gram's  discovery  of  his  differential  stain  was  a  great  achievement;  but  it  is 
not  used  by  the  general  practitioner  as  much  as  it  should  be,  for  it  is  complicated 
and  time-consuming.  In  order  that  a  method  may  be  generally  used,  it  must  em- 
ploy simple  and  stable  solutions  and  must  be  reliable  and  quick.  I  have  there- 
fore endeavored  to  simplify  and  shorten  Gram's  method,  and  my  experiments 
have  resulted  in  the  method  described  below: 

"1.  Make  a  thin  smear  on  a  cover-glass. 

2.  Dry  in  the  air. 

3.  Without  fixation,  flood  the  cover-glass,  held  by  forceps,  with  a  2  per  cent 
solution  of  crystal  violet  (Hochst,  pure)  in  methyl  alcohol.  Allow  the  stain  to  act 
for  15  seconds;  wash  off  the  stain  slowly  with  distilled  water,  by  letting  it  fail  on 
drop  by  drop  from  a  pipette;  this  takes  about  10  seconds;  then  wash  both  sur- 
faces of  the  cover-glass  briskly  with  distilled  water. 

4.  Flood  the  cover-glass  with  the  following  solution: 


Iodine, 

1  gram. 

Potassium  iodide. 

2  grams. 

Distilled  water. 

100  cc. 

Allow  this  to  act  for  15  seconds. 

5.  Pour  off  the  iodine  solution  and  pour  on  95  per  cent  alcohol,  at  first  quickly, 
then  slowly  until  no  more  color  is  given  off.     This  takes  about  10  seconds. 

6.  Wash  thoroughly  with  distilled  water  and  mount   in  water,  or — after  dry- 
ing— in  balsam. 

The  Gram-positive  bacteria  appear  bluish-black. 

"The  advantages  are:  Absence  of  fixation,  the  use  of  a  simple  methyl-alcohol 
solution  of  the  dye  which  keeps  indefinitely  instead  of  the  usual  aniline-water 
gentian-violet  solution,  which  is  troublesome  to  prepare  and  keeps  only  for  a  few 
weeks,  the  use  of  ordinary  95  per  cent  alcohol  in  place  of  the  absolute  alcohol  usu- 


392  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

ally  advised,  and  finally  the  shortening  of  the  various  steps;   the  entire  process  is? 
completed  within  one  minute  after  the  violet  stain  is  applied. 

"Gentian  violet  or  methyl  violet  may  be  used  in  the  same  manner  and  strength 
in  the  place  of  crystal  violet,  but  the  last  named  gives  the  best  results. 

'Method  alcohol  cannot  be  substituted  for  ethyl  alcohol  for  decolorizing,  be- 
cause it  dissolves  out  all  the  stain  from  the  Gram-positive  bacteria. 

"  It  is  possible  to  combine  the  violet  stain  with  iodine  in  one  solution  and  to  stain 
with  this  mixture  and  then  apply  alcohol,  which  will  remove  the  color  only  from 
the  Gram-negative  bacteria.  But  the  results  are  not  so  good,  and  the  method 
above  given  is  already  so  simple  that  I  do  not  advise  the  combination  of  the  violet 
stain  with  iodine  in  one  mixture. 

"  Experience  has  shown  that  the  alcohol  removes  the  stain  completely  from  the 
Gram-tiegative  bacteria  in  a  few  seconds,  but  will  take  it  from  the  Gram-positive 
bacteria  only  after  the  lapse  of  some  minutes." 

Significance  of  the  Microscopic  Findings. 

In  a  few  cases,  diplococci  showing  the  staining  qualities  of  gonococci  have  been 
found  in  patients  where  apparently  there  has  never  been  gonorrhoea.  But  such 
cases  are  exceptional  and  only  serve  to  show  that  the  positive  diagnosis  of  gonor- 
rhoea must  rest  on  the  clinical  symptoms  and  microscopic  findings  together,  and 
not  on  the  microscopic  findings  alone. 

As  already  stated,  in  acute  and  subacute  cases  there  is  rarely  any  difficulty  in 
determining  certainly  whether  the  trouble  is  or  is  not  gonorrhoeal. 

In  chronic  cases,  on  the  other  hand,  there  is  often  great  difficulty.  If  a  few  ap- 
parent gonococci  (shape,  groupings,  situated  in  pus  cells,  decolorized  by  Gram's 
method)  are  found,  the  diagnosis  is  not  positive  (may  be  "pseudo-gonococci"), 
though  the  strong  probability  is  that  the  lesion  is  gonorrhoeal,  if  the  history  and 
ordinary  examination  findings  point  that  way.  The  employment  of  culture  meth- 
ods by  a  skilled  pathologist  may  aid  some  in  deciding  the  question  in  a  doubtful 

case. 

If  no  apparent  gonococci  are  found  in  a  chronic  discharge,  that  is  not  proof 
that  the  lesion  is  not  gonorrhoeal.  In  many  cases  of  chronic  discharge  from  lesions 
that  are  undoubtedly  gonorrhoeal,  no  gonococci  are  found,  because  they  have 
temporarily  disappeared  from  the  secretion.  But  they  lie  hidden  in  the  tissues 
from  which  the  discharge  comes  and  are  still  capable  of  causing  infection,  and  they 
are  likely  to  be  excited  to  activity  by  anything  that  causes  pelvic  congestion,  as, 
for  example,  sexual  intercourse  or  an  attack  of  pelvic  inflammation. 

Thus  it  is  seen  that  the  presence  or  absence  of  apparent  gonococci  falls  short  of 
decisive  import  in  a  considerable  proportion  of  cases  of  chronic  discharge. 

Diagnosis  in  Doubtful  Chronic  Cases. 

In  the  doubtful  chronic  cases,  just  referred  to,  an  approximately  correct  diag- 
nosis may  be  made  by  giving  attention  to  the  following  points: 

1.  Careful  consideration  of  the  clinical  history  as  pointing  to  previous  gonor- 
rhoea or  excluding  the  same.     In  this  connection,  it  must  be  borne  in  mind  that 


DIAGNOSIS  OF  GONORRHOEA  IN  CHRONIC  CASES  393 

in  the  adult  married  woman,  particularly  after  the  vagina  has  been  toughened  Ijy 
child-bearing,  gonorrhoea  may  produce  but  slight  inflammation  of  the  vagina,  and 
hence  might  be  missed  entirely  in  the  history.  A  point  against  gonorrhoea  is  that 
the  inflammatory  trouble  was  apparently  caused  by  infection  following  labor  or 
abortion  or  by  instrumentation  or  by  some  other  sufficient  cause  aside  from 
coitus.  Remember,  however,  that  an  old  gonorrhoea  may  be  stirred  up  by  labor 
or  abortion.  From  a  chronically  inflamed  vulvo- vaginal  gland  or  cervix  uteri, 
the  infection  may  spread  upward  into  the  body  of  the  uterus  and  there  set  up  a 
puerperal  gonorrhoeal  endometritis.  This  may  be  the  first  decided  intimatiou 
the  patient  has  of  her  gonorrhoeal  infection.  The  discharge  from  such  a  fresh 
focus  usually  shows  undoubted  gonococci  in  abundance,  if  the  patient  happens  to 
be  seen  at  that  time. 

2.  Evidence  of  inflammation  of  the  urethra  or  of  the  duct  of  one  or  both  vulvo- 
vaginal glands. 

3.  The  presence  in  the  discharge  of  a  germ  presenting  the  characteristics  of  the 
gonococcus.  In  a  patient  who  has  once  had  gonorrhoea,  the  presence  in  the  dis- 
charge of  such  a  germ  is  strong  presumptive  evidence  that  the  gonorrhoeal  pro- 
cess is  still  active. 

4.  Effect  of  treatment.  A  chronic  inflammatory  trouble  due  to  the  gonococcus 
is  usually  more  resistent  to  treatment  than  when  due  to  other  causes. 

5.  Tubal  complications.  Chronic  salpingitis,  is  much  more  frequent  and  per- 
sistent in  gonorrhoeal  than  in  other  forms  of  endometritis.  Also,  it  is  more  fre- 
quently bilateral. 

6.  Sterility.  Persistent  steriUty  is  one  of  the  marked  characteristics  of  gonor- 
rhoeal inflammation,  much  more  so  than  of  the  ordinary  pyogenic  infection. 

7.  History  of  gonorrhoea  in  the  husband.  This  fact,  if  established,  would  of 
course  help  much  in  the  diagnosis  in  a  doubtful  case.  In  such  a  case  the  husband 
should  be  seen  and  questioned.  As  a  rule  no  question  on  this  point  should  be 
asked  the  wife,  as  it  might  arouse  suspicion  in  her  mind,  and  cause  domestic  trouble 
that  would  bring  more  unhappiness  than  the  pelvic  disease. 

TREATMENT. 

The  treatment  of  acute  gonorrhoea  in  women,  like  the  treatment  of  the  same 
disease  in  men,  has  been  the  subject  of  much  experimentation  and  of  many  differ- 
ent conclusions.  The  treatment  employed  by  different  authorities  varies  all  the 
way  from  the  most  active  and  radical  interference  to  practically  no  treatment 
beyond  some  external  cleansing. 

Before  stating  in  detail  the  methods,  I  would  like  you  to  get  clearly  in  mind  the 
principal  purposes  of  the  treatment.     They  are  as  follows: 

a.  To  prevent  extension  upward  of  the  disease  to  the  endometrium  and  Fal- 
lopian tubes.  The  extension  to  the  Fallopian  tubes  is  the  most  serious  result  of 
gonorrhoeal  infection  and  condemns  a  large  proportion  of  the  victims  to  chronic 
invalidism  or  to  a  serious  operation.     In  either  case,  there  will  probably  be  sterility. 

b.  To  completely  eradicate  the  infection  from  the  lower  genital  tract  so  that  no 
infective  discharge  will  remain.  As  long  as  one  spot  of  gonorrhoeal  inflammation 
remains  in  the  vagina  or  in  the  vulvo-vaginal  glands  or  in  the  urethra  or  in  the 


394  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

uterus,  the  discharge  is  infective  and  is  a  source  of  danger  to  the  patient  and  to 
those  around  her.  At  any  time,  there  may  be  an  extension  upward  to  the  tubes  or 
there  may  be  infection  of  the  eyes  of  the  patient  or  of  some  one  else  in  the  house- 
hold. It  is  probable  that  a  considerable  number  of  the  cases  of  gonorrhoeal  vul- 
vitis in  children  come  from  accidental  infection  from  a  contaminated  towel  or  closet- 
seat,  in  the  home  or  elsewhere. 

c.  To  relieve  the  discomfort  attendant  on  the  inflammation  and  to  prevent  con- 
tamination of  the  patient's  clothing  and  surrounding  objects  with  the  discharge. 

It  must  be  recognized  at  the  start  that  the  principal  influences  preventing  ex- 
tension upward  of  gonorrhoea,  are  the  resistance  of  the  tissues  and  the  barriers 
(constrictions,  cervical  mucus)  placed  in  the  canal  by  nature  for  the  purpose  of 
protecting  the  deeper  organs. 

The  strength  of  this  natural  resistance  to  the  spread  of  the  disease  varies  much 
in  different  persons.  In  some  cases  the  gonorrhoea  is  well  limited,  extending  up- 
ward not  at  all  or  only  by  short  steps  at  long  intervals.  In  other  cases  it  runs  a 
rapid  course  from  the  external  genitals  to  the  inmost  recesses  of   the  genital  canal. 

This  marked  variability  in  the  course  of  the  disease  is  easily  demonstrated  by 
closely  questioning  patients  who  give  a  history  of  gonorrhoea  some  months  or 
years  before. 

The  favorite  time  for  extension  to  the  endometrium  and  Fallopian  tubes,  is  dur- 
ing the  last  day  or  two  of  menstruation  and  the  first  few  days  following  menstrua- 
tion. 

No  measure  of  treatment  should  be  employed  that  interferes  with  the  natural 
protective  influences. 

One  point  of  particular  importance,  is  to  be  very  careful  not  to  carry  the  infec- 
tion any  further  than  it  has  already  extended.  For  example,  the  examination  and 
treatment  should  be  confined  to  the  inflamed  vulvar  surfaces  alone,  unless  there  is 
positive  evidence  (such  as  a  profuse  discharge)  that  the  trouble  has  extended 
past  the  vaginal  entrance.  Likewise  in  vaginal  gonorrhoea,  no  treatment  or  ex- 
amination should  extend  past  the  external  os  of  the  cervix  uteri,  unless  there  is 
unmistakable  evidence  that  the  gonorrhoea  has  extended  into  the  cervical  canal. 

A  second  important  point  is  to  use  no  application  or  instrumentation  that  will 
injuriously  irritate  the  surfaces.  Though  such  a  strong  irritating  antiseptic  ap- 
plication may  kill  most  of  the  gonococci  on  the  surface,  it  causes  so  much  desqua- 
mation and  irritation  of  the  surface  that  it  favors  multiplication  and  penetration 
by  the  remaining  gonococci  and  tends  to  cause,  rather  than  prevent,  extension  of 
the  process,  both  into  the  tissues  and  upward  along  the  surface. 

On  the  other  hand,  when  no  treatment  is  employed,  the  accumulating  irritating 
discharge  and  vast  colonies  of  bacteria  in  the  affected  canal,  caused  marked  irrita- 
tion, and  favor  extension  deeper  into  the  tissues  and  upward  along  the  canal. 

I  think  the  best  results  are  achieved  in  most  acute  and  subacute  cases  by  a  pro- 
gram about  as  follows: 

1.  Office  applications.  If  inspection  shows  that  the  process  is  apparently  con- 
fined to  the  vulva  (including  meatus  urinarious  and  ducts  of  the  vulvo-vaginal 
glands)  be  very  careful  not    to  carry  the  examining  finger  or    the  applicator   pv 


TREATMENT  OF  ACUTE  GONORRHOEA  395 

other  instrument  past  the  hymen  or  hymen-remnants.  Having  secured  tiie 
required  specimen  for  microscopic  examination,  the  parts  are  cleansed  and  the 
affected  surfaces  painted  over  with  a  25%  solution  of  argyrol  or  a  2%  to  5%  solu- 
tion of  protargol.  The  application  is  made  with  a  small  cotton-ball  (the  size  of 
a  bean)  caught  in  the  end  of  the  dressing  forceps  and  dipped  int(j  a  small  amount 
of  the  solution  poured  out  into  a  medicine  glass.  Or  a  cotton-wrapped  ap- 
plicator may  be  used.  Silver  nitrate  solution  (1%  to  5%)  does  very  well,  but  is 
rather  painful,  and  the  discoloration  it  causes  on  the  clothing  and  fingers  is  not 
removed  by  washing. 

After  a  free  application  of  the  medicine  has  been  made,  the  surfaces  are  dried 
and  some  drying  antiseptic  powder  dusted  in.  I  use  xeroform  and  boric  acid  (1 
to  3)  and  find  it  very  satisfactory,  and  without  the  odor  that  attaches  to  iodo- 
form. Most  any  non-irritating  antiseptic  powder  will  answer  the  purpose.  If  it 
is  found  that  the  patient  experiences  more  smarting  and  burning  after  this  drying 
of  the  surafce,  the  powder  may  be  left  off  the  next  time. 

A  large  piece  of  absorbent  cotton  is  applied  to  cover  the  vulva,  the  inner  portion 
being  so  disposed  as  to  lie  between  the  inflamed  surfaces,  to  keep  them  apart  and 
absorb  the  discharge.     The  cotton  is  held  in  place  by  a  T-bandage. 

If  the  examination  shows  that  the  process  has  extended  up  into  the  vagina  and 
the  tenderness  has  subsided  so  that  the  speculum  may  be  used  without  pain,  the 
speculum  is  introduced  and  the  affected  areas  (usually,  in  the  primary  acute  at- 
tack, the  entire  vaginal  wall  and  vaginal  surface  of  cervix)  are  painted  with  the 
25%  arg}'rol  or  one  of  the  other  solutions  above  mentioned.  The  vagina  is  then 
dried  and  the  non-irritating  antiseptic  powder  dusted  in. 

The  vulva  is  treated  in  the  same  way  and  covered  with  absorbent  cotton,  as 
above  described. 

2.  Prescriptions.  Give  the  patient  a  prescription  for  a  concentrated  antiseptic 
solution  for  making  up  an  antiseptic  wash  or  douche  solution  as  required.  I 
usually  give  the  regular  bichloride  douche  solution  (see  Formulse) . 

The  bichloride  tablets  are  cheaper,  but  they  are  dangerous  to  have  about  a  house 
where  children  live  or  may  come  visiting. 

If  the  patient  is  nervous  and  sleepless  and  upset  by  the  trouble,  give  a  prescrip- 
tion for  some  sedative  solution,  such  as  the  sodium  bromid  solution  (see  Formulse), 
with  instructions  to  take  at  8  and  10  p.  m.  and  8  a.  m.,  and  repeat  after  three  hours, 
when  very  restless. 

If  the  patient  is  not  very  nervous,  but  complains  of  marked  bladder  irritability 
(frequent  painful  urination)  give  the  hyoscyamus  and  potassium  citrate  mixture 
(see  Formula)  instead  of  the  bromide. 

If  there  is  neither  marked  bladder  irritability  nor  decided  nervous  disturbance 
requiring  a  prescription,  it  is  well  to  give  the  patient  some  one  of  the  internal 
urinary  antiseptics,  which  tend  to  prevent  extension  of  the  trouble  along  the  ure- 
thra and  tend  also  to  allay  discomfort  there,  such  as  urotropin  or  cystogen.  Tell 
her  to  get  also  a  pound  of  surgical  absorbent  cotton. 

3.  Instructions.     Give  the  patient  the  following  instructions: 

a.  When  you  reach  home,  lie  down  and  stay  in  bed  practically  all  the  time,  as 
long  as  there  are  any  acute  symptoms  (pain,  burning,  bladder  irritability).     It  is 


396  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

especially  important  to  be  quiet  in  bed  during  menstruation  and  for  some  days 
afterward. 

b.  Keep  the  bowels  well  open  every  day,  as  that  tends  to  diminish  the  pelvic 
congestion.  Free  bowel  movements  should  be  secured  by  internal  laxatives.  No 
enema  is  permissible,  ordinarily,  because  of  the  danger  of  carrying  the  infection 
into  the  rectum.     For  the  same  reason,  rectal  suppositories  should  not  be  used. 

c.  Keep  the  parts  covered  with  a  large  piece  of  absorbent  cotton,  held  in  place 
by  a  bandage  or  napkin  such  as  is  used  during  menstruation.  As  often  as  the  in- 
ner surface  of  the  cotton  is  soiled  it  should  be  removed  and  a  fresh  piece  applied. 
This  removes  the  discharge  from  the  inflamed  surfaces  and  prevents  the  irritation 
that  would  result  from  its  accumulation  there.  More  important  still,  it  prevents 
general  contamination  of  the  clothing  and  hands  and  other  surfaces  by  the  infective 
discharge.  Each  time,  after  the  patient  changes  the  dressing,  she  should  immedi- 
ately cleanse  her  hands  with  soap  and  water  and  then  in  the  antiseptic  solution 
which  she  uses  for  a  douche. 

In  explaining  to  the  patient  the  necessity  of  keeping  the  infected  surfaces  cov- 
ered with  cotton,  and  of  changing  the  cotton  often  and  of  washing  the  hands  well 
afterward  each  time,  take  particular  care  to  arouse  no  suspicion  that  might  lead 
to  domestic  infelicity. 

Your  work  is  to  lessen  suffering,  not  to  cause  it.  If  the  patient  should  become 
apprised  of  the  fact  that  her  husband  has  been  untrue  to  her  and  in  addition  has 
brought  to  her  a  loathsome  disease,  her  suffering  would  be  far  greater  than  any 
physical  distress  that  might  result  from  the  disease,  even  though  it  goes  on  to  pelvic 
suppuration  requiring  operation. 

I  have  no  sympathy  for  the  man  who  commits  adultery  and  brings  a  disease  of 
the  women  of  the  streets  to  the  pure  woman  whom  he  has  promised  to  love,  cherish 
and  protect.  He  reaps  his  reward  in  due  time.  It  is  not  to  protect  him  that  I 
mention  the  need  of  caution,  but  to  protect  the  woman  herself  from  unnecessary 
suffering.  This  can  usually  be  accomplished  by  the  exercise  of  a  little  tact.  To 
the  patient's  question,  "What  is  the  trouble?"  a  good  answer  is  "  Inflammation. "- 
Then  pass  quickly  to  the  directions  concerning  treatment.  At  a  convenient  time 
mention  that  the  discharge  is  irritating  and  that  she  must  be  careful  that  none  be 
carried  to  the  eyes  on  contaminated  fingers  or  serious  inflammation  of  the  eyes 
may  result.  The  patient  usually  becomes  so  interested  in  the  treatment  that 
she  forgets  to  inquire  as  to  the  cause  of  inflammation.  However,  if  she  asks,  as 
they  sometimes  do  even  when  having  no  suspicion,  "Doctor,  what  is  the  cause  of 
inflammation?"  I  usually  reply  that  "Inflammation  is  due  to  various  causes,"  in 
a  tone  that  shows  that  I  have  neither  the  time  nor  the  inclination  to  give  the  pa- 
tient a  course  in  medicine  in  order  that  she  may  understand  all  the  details  about 
inflammation.  This  rarely  fails  to  stop  troublesome  questions.  Of  course,  some 
patients  are  so  suspicious  that  they  will  not  stop  questioning  until  they  have  got- 
ten all  the  information  they  can  possibly  secure,  while  others  are  well  aware  of  the 
nature  of  the  trouble  and  question  the  physician  out  of  curiosity  or  to  see  if  he  has 
a  grasp  of  the  situation.  With  such  I  do  not  waste  much  time.  I  will  not  tell 
them  the  exact  nature  of  the  trouble,  when  I  do  not  think  best  to  do  so,  neither  will 
I  tell  them  an  untruth.    When  pressed  too  closely,  I  simply  remind  them  that  their 


TREATMENT  OF  ACUTE  GONORRHOEA  397 

principal  desire  is  to  get  well,  that  they  have  come  to  me  for  treatment,  that  I  am 
giving  tlieni  the  treatment,  and  have  given  them  all  the  information  necessary 
to  treatment.     If  not  satisfied  with  that  they  may  go  elsewhere. 

Of  course,  some  patients  know  or  will  probably  find  out  in  a  short  time  the  nature 
of  the  trouble.  But  I  prefer  that  they  find  out  from  some  other  source,  if  at  all. 
My  imparting  the  information,  or  confirming  that  imparted  by  some  of  their 
anxious  friends,  will  do  no  good  and  may  do  much  harm. 

d.  Use  the  weak  antiseptic  wash  every  3  to  6  hours,  depending  on  the  amount 
of  discharge.  If  the  vagina  also  is  involved,  have  the  patient,  in  addition  to  the 
external  .washing,  take  a  douche  of  the  weak  bichloride  solution  about  every  eight 
hours.  The  internal  remedies  mentioned  are  to  be  used  as  indicated  by  the  special 
symptoms  in  the  case. 

e.  The  patient  should  be  directed  to  return  for  local  treatment  every  second  or 
third  day,  provided  she  can  do  so  without  aggravating  the  inflammation. 

If  there  is  much  discomfort  in  walking  or  if  the  patient  must  come  a  long  way  to 
reach  the  office,  she  will  experience  more  benefit  from  remaining  quiet  at  home 
and  following  the  directions  already  given  for  the  treatment  there. 

4.  When  the  patient  can  come  to  the  office  without  detrimen',  treat  the 
affected  surface  just  as  described  for  the  first  visit.  Such  treatment,  so  applied 
as  to  cause  no  irritation,  seems  to  me  to  aid  materially  in  diminishing  the  patient's 
discomfort  and  in  hastening  the  subsidence  of  the  inflammation.  The  treatment 
is  repeated  every  second  or  third  day  until  all  inflammation  has  disappeared  from 
the  affected  surfaces,  the  intervals  being  gradually  lengthened  as  improvement 
takes  place. 

I  do  not  think  it  advisable  during  this  first  part  of  the  attack,  that  is,  in  the  first 
two  or  three  weeks,  to  swab  out  the  lower  part  of  the  urethra  or  of  the  cervical 
canal,  or  to  inject  medicine  into  Skene's  glands  or  into  the  ducts  of  the  vulvo- 
vaginal glands.  Such  treatment  is  likely  to  carry  the  inflammation  further  in 
than  it  might  otherwise  go,  and  may  make  permanent  an  infection  which  nature 
would  throw  off  if  given  a  little  time.  If  inflammation  in  any  of  these  situations 
persists  into  the  chronic  stage,  then  they  require  particular  treatment. 

In  those  very  severe  acute  cases  where  the  patient  suffers  a  great  deal  from  the 
burning,  itching,  smarting  and  throbbing  pain,  and  the  trouble  is  increased  when 
the  patient  stands,  she  should  be  put  to  bed  and  kept  there  until  the  most  acute 
symptoms  have  disappeared.  In  the  meantime,  she  should  follow  the  directions 
given  for  the  treatment  at  home.  If  the  weak  bichloride  solution  seems  to  cause 
any  irritation  (it  does  with  some  patients),  use  a  weak  |%  lysol  solution  or 
some  other  antiseptic  in  weak  solution.  The  potassium  permanganate  douche 
(see  Formulae)  is  effective. 

The  principal  effect  of  the  wash  and  douche  is  to  remove  mechanically  the  irri- 
tating secretion.     It  may  be  used  warm  or  tepid  or  cool,  as  found  most  agreeable. 

In  cases  where  the  smarting  and  itching  are  marked,  the  25%  argyrol  may  be 
applied  with  the  patient  in  bed,  by  bringing  the  patient  around  in  the  bed,  with 
each  foot  on  a  chair,  as  for  a  vaginal  examination  (Fig.  116).  If  neither  the 
cleansing  nor  the  argyrol  applications  relieve  the  smarting  about  the  external 
genitals,    give  the  patient    a    prescription  for  the  "lead  and  opium  wash"    (see 


398  DISEASES  OP  EXTERNAL  GENITALS  AND  VAGINA 

Formulse)  and  direct  her  to  use  it  freely,  dabbing   it  on    uith   cotton  balls  fre- 
quently enough  to  keep  the  surfaces  moist  with  it. 

In  some  of  these  severe  cases,  a  hot  sitz-bath  every  4  to  6  hours  gives  consider- 
able reUef, 

Treatment  of  Chronic  Gonorrhoea. 

A  chronic  gonorrhoea!  discharge  is  due  to  persistence  of  the  specific  inflammation 
in  one  or  more  isolated  areas.  When  such  a  discharge  persists  after  the  inflamed 
surfaces  generally  have  returned  to  normal  (i.  e,  after  3  to  6  weeks,  depending  on 
the  severity  of  the  inflammation),  make  careful  search  for  its  exact  source.  The 
situations  in  which  the  inflammation  is  likely  to  persist  are  the: 

Vulvo-vaginal  glands  or  ducts. 
Skene's  glands,  in  the  urethra. 
Upper  end  of  vagina. 
Cervix  uteri. 
Corpus  uteri. 

In  Vulvo=vaginal  Glands  or  Ducts.  Persistence  of  the  gonorrhoeal  inflammation 
in  the  duct  of  a  vulvo-vaginal  gland,  is  indicated  by  reddening  about  the  mouth  of 
the  duct  and  by  a  discharge  from  it,  a  drop  of  which  may  usually  be  pressed  out. 
Microscopic  examination  of  this  discharge  usually  shows  gonococci  in  abundance, 
though  in  some  old  cases  they  may  disappear  temporarily. 

The  treatment  for  this  condition  is  to  make  an  application  of  25%  arg}a-ol  or  5% 
to  109o  protargol  about  eveiy  other  day. 

The  acute  and  subacute  symptoms  have  all  disappeared,  and  the  patient  may 
now  come  to  the  office  as  often  as  necessary,  -udthout  any  probability  of  disturb- 
ance from  the  exercise. 

The  application  of  arg}^rol  or  protargol  to  the  interior  of  the  duct  is  made  by  a 
fine  applicator  with  a  thin  cotton  ^\Tapping. 

The  mouth  of  the  duct  should  be  opened  so  it  will  easily  admit  the  applicator 
carrying  the  medicine.  Occasionally  the  necessary  widening  may  be  effected  by 
simple  dilatation.  Usually,  however,  it  T^ill  be  necessary  to  incise  the  opening  so 
as  to  give  a  wide  entrance. 

A  small  piece  of  cotton  soaked  in  20%  cocaine  solution  is  laid  over  the  area,  a 
small  amount  being  pushed  into  the  opening  a  short  distance.  Leave  this  in  place 
5  minutes.  Then  introduce  into  the  duct  the  sharp  point  of  a  slender  bistoury 
and  make  a  cut  outward  or  downward  from  an  eighth  to  a  quarter  of  an  inch.  If 
the  external  application  of  cocaine  does  not  obtund  the  sensibility,  as  tested  by 
the  bistoury  point  before  cutting,  inject  some  ^-%  cocaine  solution  or  some  of  the 
Schleich  solution  No.  2  (see  Formula?)  into  the  area  to  be  incised. 

When  the  duct  is  thus  made  accessible,  make  a  thorough  applicati^m  to  its  in- 
terior, taking  care,  however,  not  to  carry  the  infection  into  the  gland  if  it  has  not 
already  gotten  there. 

The  other  duct  if  involved  is  treated  the  same  way. 


TREATMENT  OF  CHRONIC  GONORRHOEA  399 

If  the  inflammation  subsides  the  appHcations  are  kept  up  until  all  discharge 
ceases,  lengthening  the  intervals  as  improvement  takes  place. 

There  are  usually  other  points,  as  in  Skene's  glands,  or  in  the  cervix,  that  require 
treatment  at  the  same  time. 

If  no  decided  improvement  appears  after  a  few  applications,  the  affected  duct 
with  its  gland  needs  to  be  extirpated.  Also,  if  the  gland  shows  evidence  of  chronic 
involvement  (firm  nodule  in  that  situation)  it  requires  extirpation,  for  as  long  as 
it  remains,  it  prevents  complete  cure  and  the  discharge  from  it  is  a  source  of  danger. 

If  an  abscess  forms  in  the  gland,  it  is  allowed  to  develop  until  the  gland  is  proba- 
bly destroyed  and  the  collection  is  near  the  surface,  covered  only  by  a  thin  wall  of 
tissue.     It  is  then  opened  freely. 

If  the  abscess  is  well  developed  so  that  all  septa  are  destroyed  and  the  recesses 
form  part  of  the  main  cavity,  there  may  be  complete  healing  afterward  and  an  end 
of  the  trouble.  If  a  second  abscess  forms  later,  however,  that  means  that  portions 
of  the  infected  gland  remain,  and  in  such  a  case,  all  the  involved  indurated  tissue 
should  be  extirpated,  after  the  abscess  has  been  drained  and  all  acute  symptoms 
are  gone.  When  it  is  necessary  to  wait  a  few  days  for  an  abscess  to  get  in  good 
condition  for  opening,  the  patient  is  directed  to  stay  in  bed  and  make  hot  applica- 
tions of  absorbent  cotton  wrung  out  of  very  hot  water  or  weak  antiseptic  solution, 
and  covered  with  oil  silk.  As  a  rule  the  pain  is  not  severe  until  the  abscess  is  ready 
to  open  or  about  ready  to  break. 

Then  the  patient  may  come  to  the  office,  or,  if  movement  is  very  painful,  it  may 
be  opened  at  her  home. 

In  Skene's  Glands.  When  the  gonorrhoeal  inflammation  invades  these  peri- 
urethral ducts  it  may  remain  there  indefinitely,  causing  symptoms  of  chronic  ure- 
theritis  or  chronic  cystitis  and  a  persistent  infective  discharge.  There  is  redness 
about  the  urethra  and  pouting  outward  of  the  swollen  urethral  mucosa.  If  the 
patient  has  passed  through  parturition,  the  opening  of  the  duct  on  each  side  may 
usually  be  seen  by  rolling  out  the  urethral  mucosa  (Fig.  48) .  If  the  duct  is  open 
a  drop  of  pus  may  be  pressed  from  it.  If  the  duct  is  closed,  a  small  abscess  forms 
in  it. 

To  treat  these  conditions,  apply  a  pledget  of  cotton  soaked  in  a  20%  solution  of 
cocaine,  pushing  a  part  of  it  a  short  distance  into  the  urethra.  Leave  this  in  place 
five  minutes  and  then  proceed  as  follows: 

If  the  duct  is  open,  inject  a  25%  solution  of  argyrol  into  it  with  a  hypodermic 
syringe.  Use  a  needle  the  point  of  which  has  been  filed  round  and  smooth,  so  it 
will  easily  pass  into  the  duct  without  penetrating  the  wall.  Fill  the  duct  with  the 
solution  so  that  it  comes  in  contact  with  all  the  recesses.  This  is  simply  a  small 
duct.  There  is  no  gland  back  of  it,  into  which  infection  may  be  carried,  so  the 
medicine  may  be  injected  freely.  This  injection  is  repeated  every  few  days,  at 
the  same  time  that  other  infected  structures  are  treated. 

If  the  inflammation  persists  in  spite  of  this,  then  dilate  the  urethra  and  slit  open 
the  ducts  and  treat  their  interior  directly  with  the  solutions  already  mentioned. 
Some  prefer  to  make  very  strong  applications  to  the  ducts  after  they  are  slit  open, 
for  example,  carbolic  acid  and  tincture  of  iodine,  half  and  half..  The  slitting  open 
and  treatment  of  Skene's  ducts  may  be  done  under  cocaine  anesthesia.     In  some 


400  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

cases  there  are  other  chronically  infected  areas  that  need  painful  treatment  re- 
quiring a  general  anesthetic  (extirpation  of  a  vulvo-gland  or  dilatation  and  curet- 
ment  of  the  uterus  or  excision  of  infected  cervical  tissue) ,  and  the  urethral  ducts 
may  be  taken  care  of  at  the  same  time. 

In  Vaginal  Vault.  Persistent  inflammation  at  the  vaginal  vault  is  due  usually 
to  an  irritating  and  infective  discharge  from  the  cervical  canal.  The  chronic 
uterine  infection,  may  be  located  in  the  cervix  or  in  the  body  of  the  uterus.  The 
treatment  of  these  conditions  will  be  found  under  inflammatory  diseases  of  the 
uterus  (see  chapter  vi.). 

Occasionally  there  will  be  persisting  inflammation  of  the  vaginal  vault  without 
involvement  of  the  cervical  canal,  the  cervical  discharge  being  practically  clear 
mucus,  though  considerably  increased  in  amount  by  the  hyperemia. 

Whether  the  inflammation  at  the  vaginal  vault  exists  alone  or  is  secondary  to 
chronic  gonorrhoeal  endocervicitis  or  endometritis,  it  requires  treatment.  There 
are  two  methods  of  treatment — the  glycerine-tampon  treatment  and  the  dry 
treatment. 

1.  Glycerine-tampon  Treatment.  Introduce  the  speculum,  expose  the  cer- 
vix and  vaginal  vault,  cleanse  the  surfaces  with  an  antiseptic  solution,  and  tieat 
the  interior  of  the  cervix  if  it  requires  treatment.  Cleanse  the  surfaces  again  and 
dry  them  and  then  apply  a  25%  argyrol  or  10%  protargol  or  10%  silver  nitrate 
solution  to  the  vaginal  vault  and  vaginal  surface  of  the  cervix. 

Wipe  out  the  excess  of  fluid  and  then  apply  an  absorbent-cotton  tampon  with 
the  inner  end  soaked  in  10%  ichthyol-glycerine  or  10%  protargol-glycerine.  It  is 
supposed  that  the  glycerine,  by  its  hygroscopic  action,  helps  to  work  the  deeper 
gonococci  towards  the  surface,  where  they  may  be  acted  on  by  the  antiseptic. 

The  tampon  should  be  packed  in  rather  firmly,  so  as  to  stretch  the  vaginal  wall. 
This  firm  packing  of  the  vaginal  vault,  smooths  out  the  wrinkles  and  brings  the 
gonococci  nearer  the  surface.  It  has  much  the  same  effect  that  the  passage  of  a 
large-sized  sound  has  in  chronic  gonorrhoeal  urethritis  in  the  male. 

This  firm  tamponade  of  the  upper  part  of  the  vagina  is  best  applied  with  the  pa- 
tient in  Sims'  posture  or  in  the  knee-chest  posture. 

If  there  is  much  uterine  discharge,  this  tampon  must  be  removed  by  the  patient 
in  8  to  12  hours,  and  the  antiseptic  douches  continued  until  she  returns  in  two  or 
three  days  for  the  next  treatment. 

If  the  uterine  discharge  is  slight,  the  tampon  may  be  left  in  24  hours,  and  then 
removed  and  the  douches  continued  until  the  next  treatment. 

If  there  is  decided  infiltration  and  thickening  of  the  vaginal  wall,  it  may  be  ad- 
vantageous to  use  25%  ichthyol-glycerine  on  the  tampon,  for  a  few  times.  This 
causes  desquamation  of  the  superficial  layers  of  the  vaginal  mucosa,  thus  bringing 
the  medicine  closer  to  the  bacteria,  and  permitting  better  penetration  of  the  affected 
tissues  by  the  medicine. 

2.  Dry  Treatment.  Expose  the  vaginal  vault  with  the  speculum,  cleanse  the 
surfaces,  treat  the  interior  of  the  cervix,  if  it  needs  treatment,  and  cleanse  the  sur- 
faces again.  Dry  the  vault  well  and  apply  the  25%  argyrol, or  10%  protargol  or 
10%  silver  nitrate  to  the  affected  surfaces. 

Apply  this  thoroughly  and  let  it  soak  into  all  the  fine  depressions.     Then  dry 


GONORRHOEA  IxN   CHILDREN  4()1 

the  wall  again  and  dust  in  a  lai-ge  amount  of  some  astringent-antiseptic  drying 
powder.  I  use  a  powder  composed  of  tannic  acid  (1  part),  xeroform  (1  part) 
and  boric  acid  (3  parts).     This  is  put  in  freely  with  the  powder-blower. 

For  throwing  powders  in  large  quantity  into  the  upper  part  of  the  vagina,  I 
find  the  ordinary  8-ounce  Politzer-bag  very  convenient.  The  tip  is  unscrewed,  the 
bag  filled  about  one-third  full  of  the  powder  and  the  tip  screwed  on  again.  Now, 
by  tipping  the  bag,  the  powder  runs  into  the  tube,  and  little  or  much,  as  desired, 
may  be  thrown  to  the  top  of  the  vagina.  If  the  tube  clogs  with  powder,  turn  the 
tube  end  up  and  tap  the  bottom  of  the  bag  on  some  solid  surface.  This  jars  the 
powder  out  of  the  tube  and  clears  it  for  use.  Of  course,  if  the  powder  gets  damp, 
then  the  tube  must  be  cleansed  with  an  applicator,  and  possibly  the  bag  emptied 
and  fresh  powder  put  in. 

After  the  powTler  has  been  dusted  into  the  vagina,  then  a  good-sized  cotton  or 
wool  tampon  is  spread  at  its  upper  end  and  a  quantity  of  the  same  powder  placed 
in  the  depression,  and  the  tampon  carried  to  the  vaginal  vault.  One  or  two 
smaller  ones  may  be  packed  below  it  to  hold  it  well  in  place.  This  constitutes  a 
"dry  treatment." 

If  there  is  but  little  discharge  from  the  cervix,  this  tampon  may  be  left  in  place 
for  two  days,  the  patient  returning  then  to  have  it  renewed.  In  such  a  case  the 
powder  should  be  dusted  in  freely  between  the  tampons,  in  order  to  have  a  strong 
antiseptic  effect  and  prevent  decomposition  during  the  two  days  that  the  tampon- 
ade is  in  place. 

When  the  patient  returns  the  tamponade  is  removed,  the  vagina  thoroughly 
cleansed  and  another  dry  treatment  given. 

These  are  continued  until  the  vaginal  wall  has  apparently  returned  to  a  normal 
condition,  then  the  treatment  is  stopped  and  the  case  watched. 

Examinations,  to  determine  the  amount  of  discharge  and  the  condition  of  the 
vaginal  vault,  are  made  at  intervals  of  a  week  or  so,  and  also  microscopic  tests  of 
any  discharge  that  appears. 

In  a  case  where  there  is  much  uterine  discharge,  the  tamponade  must  be  re- 
moved in  24  hours  and  antiseptic  douches  continued  until  the  patient  returns  for 
the  next  treatment.  In  such  a  case  the  tampons  must  be  arranged  with  strings 
so  that  the  patient  may  remove  them  easily.  This  modified  dry  treatment  is 
very  useful  in  cases  where  an  endocervicitis  is  being  treated  at  the  same  time. 
However,  in  the  cases  of  persistent  uterine  discharge,  it  is  useless  to  continue 
this  treatment  except  as  a  palliative  measure.  As  long  as  the  infective  uterine 
discharge  continues,  there  will  necessarily  be  irritation  of  the  vaginal  vault.  In 
such  a  case,  effective  treatment  for  the  chronic  uterine  inflammation  is  the  import- 
ant matter. 

In  Cervix  and  Corpus  Uteri.  Gonorrhoeal  inflammation  of  the  uterus  is  consid- 
ered in  chapter  vi. 

Gonorrhoea  in  Children. 

Gonorrhoeal  inflammation  in  female  infants  and  children  is  more  frequent  than 
is  generally  supposed.  In  any  case  of  severe  or  persisting  discharge  from  the 
vulva,  microscopic  examination  should  be  made  in  order  to  establish  the  presence 
or  absence  of  gonorrhoea. 


402  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

In  infants  and  children  the  process  is  more  likely  to  be  confined  to  the  external 
genitals,  for  usually  there  has  been  no  penetration  into  the  vagina  by  the  infecting 
a^ent.  Some  of  these  cases  are  due  to  rape,  but  probably  the  most  of  them  are 
due  to  accidental  contamination  from  soiled  clothing  or  closet-seat  or  from  the 
nngers  of  the  mother  or  attendant. 

The  principles  of  treatment  are  the  same  as  for  the  adult — namely,  frequent 
cleansing,  the  use  of  a  reliable  gonocide  preparation  and  the  exercise  of  care  not  to 
carry  the  infection  higher  than  the  surfaces  already  involved. 

Particular  care  should  be  taken  to  instruct  the  mother  as  to  frequent  cleansing 
of  the  parts  with  warm  water  or  with  a  mild  antiseptic  wash  and  as  to  keeping  the 
parts  covered  to  pervent  contamination  of  the  clothing  by  the  discharge.  Argyrol 
is  an  excellent  gonocide  for  use  in  these  cases,  as  it  causes  little  or  no  pain.  Start 
with  a  weak  solution  (5%)  and  advance  to  the  stronger  (25%)  as  the  patient  be- 
comes accustomed  to  it.  If  the  vagina  is  involved,  the  washing  out,  and  also  the 
application  of  the  gonocide,  may  be  carried  out  through  a  small  soft-rubber 
catheter, 

SIMPLE  VULVITIS. 

Simple  vulvitis  is  superficial  inflammation  of  the  external  genitals  due  to  irri- 
tation or  to  infection  with  ordinary  pus  germs.  Sometimes  it  takes  the  form  of 
scalding  or  chafing. 

Etiology. 

The  predisposing  causes  of  simple  vulvitis  are  poor  general  health,  and  local  con- 
ditions which  cause  pelvic  congestion,  for  example,  pregnancy  and  pelvic  tumors. 
The  exciting  causes  are  as  follows: 

1.  An  irritating  vaginal  discharge.  In  the  various  forms  of  acute  vaginitis  and 
acute  endometritis,  the  discharge  alone  may  be  sufficiently  irritating  to  cause  pro- 
nounced vulvitis. 

In  chronic  vaginal  discharge  there  may  be  considerable  itching,  and  the  conse- 
quent scratching  and  friction  is  principally  responsible  for  the  inflammation.  In 
children  this  is  a  very  frequent  cause  of  troublesome  and  persistent  vulvitis. 

2.  Irritating  urine.  Dia"  ;uic  urine  may  cause  vulvar  irritation  with  resulting 
chronic  inflammation  and  thickening  of  the  tissues.  In  this  condition  there  is  a 
brawny  induration  with  sometimes  considerable  enlargement.  Other  substances 
in  the  urine,  such  as  pus,  or  high  concentration  of  the  urine,  may  cause  irritation 
leading  to  scratching  and  consequent  vulvitis. 

3.  Parasitic  affections.  In  pediculosis  pubis,  the  pediculi  are  located  about  the 
pubic  hairs,  where  they  cause  much  itching  and  irritation  and  may  lead  to  vulvitis. 
Ascarides  (the  thread-worm  from  the  rectum)  may  cause  severe  scratching  and 
vulvitis.  In  persistent  vulvitis  in  children  without  apparent  cause,  the  stools 
should  be  examined  for  the  presence  of  the  thread- worm  or  "seat- worm"  as  it 
is  sometimes  called. 

4.  Masturbation.  Friction  from  masturbation  may  lead  to  inflammation  of 
the  external  genitals.  There  is  usually  some  irritant  that  first  causes  scratching 
and  the  masturbation  is  an  after-development.     In  children  this  may  lead  to  se- 


TREATMENT  OV  SIMl'I.K   VULVITIS  4(J3 

vere  vulvitis.     In  older  persons  it  more  frequently  causes  simply  hypertrophy  of 
the  labia  minora. 

5.  Lack  of  cleanliness.  In  exceptional  cases,  this  alone  may  act  as  a  cause, 
but  usually  it  serves  only  to  aggravate  the  irritation  due  to  some  of  the  other 
causes  mentioned. 

6.  Acute  exanthemata.  In  eruptive  diseases,  the  same  process  that  affects  the 
skin  elsewhere  may  effect  the  vulva  where,  on  account  of  the  local  heat  and  moist- 
ure, there  may  result  much  irritation  and  inflammation. 

Pathology. 

In  acute  vulvitis  there  are  the  usual  signs  of  inflammation,  the  intensity  of  the 
signs  depending  on  the  severity  of  the  process.  If  very  severe  or  if  there  has  been 
much  scratching,  there  may  be  denuded  areas  discharging  serum  or  pus.  If  the 
inflammation  has  been  present  a  long  time  and  is  consequently  in  the  chronic 
stage,  there  is  cellular  infiltration  of  the  tissues,  with  induration  and  discoloration 
and  frequently  considerable  hypertrophy. 

Symptoms  and  Diagnosis. 

The  symptoms  are  itching  and  burning  and  heat  about  the  genitals,  ^\dth  red- 
ness, swelling  and  discharge.  There  may  be  many  abrasions  due  to  scratching, 
and  also  small  ulcers  from  the  same  cause.  Often  there  is  burning  on  urination 
and  increased  frequency  of  urination.  In  the  chronic  stage,  the  secondary  condi- 
tions just  mentioned  under  pathology  are  noticeable. 

Gonorrhoeal  vulvitis  is  distinguished  by  the  characteristics  mentioned  under 
gonorrhoea.  In  this  connection  it  must  be  kept  in  mind  that  simple  vulvitis  may, 
in  exceptional  cases,  lead  to  simple  urethritis  in  the  patient  and  even  in  her  hus- 
band. 

Treatment. 

After  determining  certainly  that  gonorrhoea  is  not  present  (for  it  requires  more 
active  measures)  proceed  with  the  treatment  of  the  simple  vulvitis  as  follows: 

1.  Secure  cleanliness.  The  parts  should  be  washed  several  times  daily  with  a 
carbolic  solution  or  other  mild  antiseptic  solution. 

I^      Acid  Carbolici 

Glycerini,  aa  90  c.c. 

Sig.    Teaspoonful  to  a  pint  of  water.     Use  as  a  wash  several  times 
daily. 

Small  balls  of  absorbent  cotton  are  very  convenient  for  applying  the  wash  to 
the  surface  and  for  removing  the  discharge.  This  keeps  the  parts  clean  and  to 
some  extent  relieves  the  itching.  After  each  washing,  the  parts  should  be  thoroughly 
dried  and  then  kept  dry  by  being  dusted  freely  with  some  drying  powder,  for 
example,  stearate  of  zinc  or  bismuth  subgallate  or  bismuth  subnitrate  or  boric 
acid  or  equal  parts  of  bismuth  subcarbonate  and  prepared  chalk  or  one  of  the 
numerous  preparations  of  "talcum  powder"  prepared  for  toilet  use.     The  in- 


404  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

flamed  surfaces  should  be  kept  separated  by  a  pledget  of  cotton  placed  between 
them  and  renewed  as  soon  as  it  becomes  wet  with  the  discharge. 

2.  Remove  the  cause.  If  the  vulvitis  is  due  to  a  discharge  from  vaginal  or 
uterine  disease,  the  nature  of  the  disease  must  be  determined  and  appropriate 
treatment,  as  described  elsewhere,  employed.  In  the  case  of  uterine  disease,  if 
the  discharge  can  not  be  checked  at  once  it  may  be  kept  from  irritating  the  vulva 
by  tampons  placed  against  the  cervix  and  renewed  often  enough  to  absorb  the  dis- 
charge. 

In  children  there  is  often  what  seems  to  be  simply  loss  of  tone  with  excessive 
secretion,  giving  a  vaginal  discharge.  If  this  condition  does  not  yield  to  tonic 
treatment  and  external  cleansing  measures,  the  treatment  described  for  vaginitis 
in  children  should  be  employed  (see  page  415). 

If  diabetes  or  other  marked  urinary  disturbance  is  present,  it  ^dll  be  discovered 
in  the  urine  analysis,  and  must  be  given  suitable  treatment.  In  pediculosis  pubis, 
a  few  inunctions  of  oleate  of  mercury  will  kill  the  parasites.  If  ascarides  cause 
the  trouble,  give  the  following  enema  every  other  day  until  the  worms  disappear. 

^      Infus.  Quassiae,  120  cc. 

Sig.     Four  tablespoonfuls  to  a  pint  of   warm  water.     To  be   used  as 
a  rectal  injection,  as  directed. 

In  masturbation,  remove  all  local  irritation,  keep  the  genitals  cleansed,  give 
bromides  to  diminish  the  irritability  of  the  sexual  center  and,  if  necessary,  appea' 
to  the  reason  and  pride  and  fear  of  the  child  or  adult,  as  the  case  may  be,  to  pre- 
vent the  continuance  of  the  habit. 

3.  Make  sedative  or  astringent  applications.  If  the  inflammation  is  acute  and 
accompanied  by  burning  and  itching,  not  relieved  b}'  the  cleansing  measures,  the 
lead  and  opium  wash  (see  Formulae)  may  be  used.  A  thick  layer  of  absorbent 
cotton,  or  a  soft  cloth,  should  be  soaked  in  this  solution  and  applied  to  the  geni- 
tals after  the  cleansing  w^th  the  carbolic  wash.  The  lead  and  opium  mixture  may 
be  kept  applied  to  the  genitals  as  long  as  the  severe  burning  and  smarting  are 
present.  It  usually  gives  the  desired  relief.  The  borax  and  opium  wash  (see 
Formulae)  is  another  sedative  application  w^hich  is  used  in  the  same  way.  In 
some  cases  it  may  be  necessary  to  apply  cocaine  solution  (4%)  occasionally,  when 
the  irritation  is  most  marked.  A  small  piece  of  absorbent  cotton  wet  in  the  solu- 
tion may  be  rubbed  over  the  inflamed  areas  or  applied  to  them  for  several  minutes. 
Continuous  applications  of  cocaine  solution  for  any  considerable  length  of  time  is 
not  advisable  on  account  of  the  danger  of  absorption. 

In  some  cases  in  which  an  irritating  discharge  from  the  vagina  or  urethra  can 
not  be  stopped,  the  surfaces  coming  in  contact  with  it  may  be  somewhat  protected 
by  covering  them  with  zinc  oxide  ointment.  The  ointment  should  be  applied  each 
time  after  the  gentials  have  been  cleansed  with  the  carbolic  wash  and  wiped  dr}-. 
The  addition  of  carbolic  acid  (2%  to  5%)  makes  the  ointment  more  effective  in 
relieving  pruritis.  If  this  does  not  give  relief,  cocaine  (2%  to  10%)  may  be 
ad  I  led. 

Astringent  and  antiseptic  applications  have  a  direct  effect  toward  diminishing 
the  disease,  and  in  most  cases  they  can  ])e  used  from  the  first.     If  the  inflammation 


ERYSIPELAS  OF  VULVA 


405 


is  acute  and  is  accompanied  by  much  discharge,  the  25%  argyrol  solution  is  bene- 
ficial. It  should  be  applied  carefully  over  all  the  inflamed  surface  every  second 
or  third  or  fourth  day.  The  zinc  sulphate  and  hydrastis  wash  (see  Formula;)  is 
a  good  astringent  application  which  may  be  applied  by  the  patient. 

4.  Internal  Treatment.  Administer  tonics  or  sedatives  or  other  internal  reme- 
dies as  indicated  by  the  conditions  present.  Patients  in  poor  general  health  should 
have  appropriate  tonic  treatment.  If  there  is  chronic  constipation,  laxatives 
should  be  given.  If  there  is  much  urethral  irritation,  as  indicated  by  frequent  or 
])ainful  urination,  give  the  hyo8C}'amos  and  potassium  citrate  mixture  (see  Formu- 
hc).  If  the  urine  is  concentrated,  direct  the  patient  to  drink  an  abundance  of 
water.  Lemonade,  not  too  sweet,  is  pleasant  for  a  change  and  helps  to  make  the 
urine  less  irritating; 

If  the  patient  loses  sleep  or  is  made  nervous  by  the  vulvar  irritation,  it  is  well 
to  administer  a  mild  sedative,  such  as  sodium  or  strontium  bromide. 

FOLLICULAR  VULVITIS. 

Follicular  vulvitis  occurs  in  adults.  It  is  characterized  by  the  inflamma- 
tion being  confined  principally  to  the  hair  follicles  and  sebaceous  glands,  the  in- 
flamed structures  being  represented  by  small  red  papules  scattered  over  the  labia 
(Fig.  216). 

The  causes,  symptoms  and  treatment  are  the  same  as  described  under  simple 
vulvitis.  This  form  of  vulvitis  is  prone  to  become  chronic  and  resist  treatment, 
consequently  it  should  be  treated  vigorously.  The  measures  mentioned  under 
simple  vulvitis  (acute  and  chronic)  should  be  used.  Also  the  following  sometimes 
gives  relief. 

i^     Liq.  Ferri  Subsulphatis,  4. 

Glycerini,  qs.  ad.,  30. 

Sig.     Apply  two  or  three  times  daily  with  a  camels-hair  brush. 

If  pus  forms  in  the  follicles,  they  should  be  evacuated  and  then  washed  out  with 
Iwdrogen  peroxide.  If  there  is  much  local  inflammation,  hot  compresses  wrung 
out  of  weak  carbolic  solution  may  give  much  relief. 

Follicular  vulvitis  sometimes  appears  during  pregnancy  and  disappears  spon- 
taneously afterward.  In  rare  cases  the  irritation  has  become  so  severe  that  it 
caused  abortion. 

ERYSIPELAS  OF  VULVA. 

Erysipelas  of  the  vulva,  like  erysipelas  elsewhere,  is  a  rapidly  spreading  inflam- 
mation produced  by  the  streptococcus  pyogenes. 

Etiology  and  Pathology.  The  streptococcus  pyogenes,  or  "streptococcus  ery- 
sipelatis,"  as  it  is  sometimes  called,  enters  through  a  crack  or  scratch  or  abrasion 
or  other  open  place  in  the  protecting  epithelium.  Once  within  the  subepithelial 
tissue  it  multiplies  rapidly,  causing  marked  inflammation  with  a  superficial  parch- 
ment-like induration  of  the  involved  surface.     There  is  also  inflammatory   edema 


406  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

of  the  deeper  tissues,  causing  marked  swelling  of  the  vulva.  The  infk,mmatory 
process  spreads  rapidh'  by  a  well  defined  margin  which  is  red  and  slightly  raised. 

If  the  inflammation  is  intense,  small  vesicles  may  appear  at  various  places  on 
the  surface  and  rupture,  discharging  serum.  The  process  may  extend  up  onto 
the  abdominal  wall  or  out  onto  the  thighs  or  into  the  vagina. 

Symptoms  and  Diagnosis.  In  tire  beginning  there  is  usually  a  chill,  followed  by 
considerable  fever  and  the  general  disturbance  usually  associated  with  fever. 
The  patient  complains  of  heat  and  throbbing  in  the  external  genitals.  The  fever 
continues  and  swelling  of  the  vulva  is  noticed.  The  patient  then  comes  for  exam- 
ination, wliich  reveals  the  condition  described  under  pathology.  Later,  pus  may 
form.  In  the  diagnosis,  differentiate  from  scarlatinal  rash  on  vulva,  from  inter- 
trigo, from  bichloride  rash,  from  cellulitis  of  vulva  and  from  hematoma. 

Treatment.  Considerable  relief  will  be  afforded  by  applying  pieces  of  absorl^ent 
cotton,  or  gauze,  soaked  in  carbolized  olive  oil  (1  to  2%).  The  exclusion  of  air 
seems  to  diminish  the  burning.  The  application  of  an  ice-bag  outside  the  oil  dress- 
ing, tends  to  check  the  pruritis  and  the  swelling.  The  bowels  should  be  moved 
well.  If  the  fever  is  high,  it  may  be  reduced  by  cool  sponge-baths  or  by  some  of 
the  reliable  antipyretics.  Quinine  in  moderate  doses  and  tincture  of  tlie  chloride 
of  iron  in  large  doses  are  time-honored  remedies  for  infective  processes.  An  abund- 
ance of  water  should  be  given  to  lielp  the  skin  and  kidneys  in  elimination.  If  the 
patient  is  weak,    strychnia  and  other  stimulants  and  tonics  are  indicated. 

In  serious  cases,  some  reliable  antistreptococcus-serum  should  be  used  freely. 
I  have  much  confidence  in  Steam's  streptolytic  serum,  which  I  have  used  with 
satisfactory  results  several  times.  In  a  recent  puerperal  case  of  rapidly  spreading 
erysipelas  of  the  brea.st,  with  a  temperature  of  106°,  the  piocess  was  promptly 
cliecked  by  tlie  free  administi ation  of  this  serum.  On  the  other  hand,  in  some  cases, 
the  serum  has  no  apparent  effect.  The  ''opsonin"  treatment  elaborated  by 
Wright,  promises  to  be  of  benefit  in  all  infective  processes,  but  it  is  still  in  the 
experimental  stage. 

Unguentum  Crede  is  an  excellent  local  application  for  the  inflamed  area.  Other 
local  applications,  found  by  experience  to  be  more  or  less  effective,  are  the  bichloride 
ointment  (see  Formula^),  carbolized  licjuid  vaseline  (o'^i  painted  over  the  surface 
with  a  camels-hair  brush,  ichthyol  and  glycerine  equal  parts  or  ichthyol  and  vase- 
line equal  parts. 

Subcutaneous  injection  of  various  antiseptic  solutions  at  the  spreading  margin, 
has  been  recommended.  But  this  gives  the  patient  considerable  pain,  and  the 
results  are  uncertain  and  not  encouraging. 

If  collections  of  pus  form,  they  should  be  incised  and  the  cavities  washed  out  with 
hydrogen  peroxide  and  drained. 


PHLEGMONOUS  VULVITIS. 

Phlegmonous  vulvitis  is  that  form  in  which  the  bacteria  (u.'^ually  the  staphylo- 
coccus pyogenes  aureus  or  alijus)  penetrate  to  the  subcutaneous  connective  tissue 
and  cause  inflammation  there.     It  is  known  also  as  "cellulitis"  of  vulva  and  as 


GANGRENOUS  VULVITIS  407 

"lymphangitis"  of  vulva.  It  lacks  tlio  superficial  parclunont-liko  imluration  of 
erysipelas. 

Etiology  and  Pathology.  Anything  that  causes  an  abrasion  about  the  vulva, 
through  which  bacteria  may  reach  the  connective  tissue,  may  lead  to  phlegmonous 
\ulvitis.  Any  of  the  previously  mentioned  forms  of  vulvitis  may  be  followed  by 
this  form.  Injuries  to  the  vulva  or  furunculosis,  may  lead  to  the  same.  The 
]iathologioal  changes  are  the  same  as  in  phlegmons  elsewhere.  There  is  marked 
inflammation  of  the  connective  tissue  and  of  the  lymph  channels.  Resolution  may 
take  place  or  the  process  may  go  on  to  suppuration.  Occasionally  suppuration 
of  the   inguinal  lymphatic  glands  occurs. 

Symptoms  and  Diagnosis.  The  symptoms  are  those  of  simple  vulvitis  with  the 
addition  of  pain  and  swelling,  indicating  deeper  inflammation.  Sometimes  there 
is  considerable  fever,  but  not  always.  The  swelling  may  be  very  marked,  the 
inflammatory  exudate  sometimes  distending  certain  structures  almost  beyond 
recognition. 

It  may  be  confoimded  with  hematoma  of  vulva.  Tli-e  latter  is  distinguished  by 
the  sudden  onset  following  some  injury  or  slight  surgical  procedure,  for  example, 
the  introduction  of  a  hypodermic  needle  for  the  purpose  of  drawing  off  fluid  from 
a  cyst.  The  hematoma  begins  within  a  few  hours  after  the  injury  and  increases 
I'apidly  in  size,  with  pain  l3ut  no  fever.  The  distinctive  signs  of  acute  inflammation 
are  absent.  Hematoma  sometimes  occurs  in  pregnancy  without  injury,  being  due 
to  subcutaneous  rupture  of  a  varicose  vein. 

When  a  phlegmonous  vulvitis  is  confined  to  one  side,  it  may  resemble  pudendal 
hernia  or  pudendal  hydrocele.  In  each  of  these  affections,  acute  inflammation  is 
absent  at  first  and,  also,  there  are  special  characteristics  that  indicate  the  nature 
of  the  swelling. 

Treatment.  The  treatment  is  the  same  as  for  celluUtis  or  lymphangitis  else- 
where. The  patient  should  stay  in  bed,  and  hot  compresses,  made  by  wringing 
absorbent  cotton  out  of  hot  water  or  weak  carbolic  solution,  may  be  applied  to 
relieve  the  pain  and  limit  the  inflammation.  If  there  is  much  superficial  irrita- 
tion it  may  be  diminished  by  the  measures  given  under  simple  vulvitis. 

Pelvic  congestion  should,  as  far  as  possible,  be  overcome  by  laxatives  and  other 
measures  as  indicated.  Hot  sitz-baths  sometimes  give  decided  relief.  If  the 
inflammation  is  severe  and  spreading  rapidly,  it  may  be  advisable  to  make  several 
incisions  through  the  involved  area,  such  as  are  made  for  severe  spreading  sub- 
cutaneous inflammation  in  other  localities.  If  an  abscess  forms,  it  must  be  opened 
and  drained. 

GANGRENOUS  VULVITIS. 

This  is  known  also  as  noma.  It  is  inflammation  of  the  vulva  of  such  severity 
that  the  nutrition  of  the  structures  is  cut  off  and  they  become  gangrenous.  Ex- 
tensive sloughing  may  take  place. 

Gangrenous  vulvitis  occurs  almost  exclusively  in  patients  in  whom  the  normal 
tissue  resistance  has  been  destroyed  by  exhausting  general  or  local  diseases.  Local 
conditions  interfering  with  the  pelvic  circulation,  such  as  pregnancy  and  pelvic 
tumors,  predispose  to  this  affection. 


408  ■  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

Its  most  frequent  victims;  however,  are  children  who  are  poorly  nourished  and 
poorly  cared  for.  In  such  it  is  often  fatal.  The  exanthemata,  particularly  when 
occurring  in  sickly  children,  may  cause  gangrenous  vulvitis. 

The  treatment  is  the  same  as  for  phlegmonous  vulvitis,  with  the  addition  of  tonics 
and  stimulants,  as  indicated  by  the  patients  general  condition.  In  some  cases  it 
may  be  advisable  to  excise  the  gangrenous  tissue  and  cauterize  the  remaining 
wound.  The  ulcerated  surfaces  remaining  after  the  sloughs  separate,  require  the 
regular  treatment  for  ulcers  of  the  vulva. 

DIPHTHERITIC  VULVITIS. 

Diphtheritic  vulvitis,  like  diphtheritic  vaginitis,  is  simply  diphtheria  with 
anomalous  location  of  the  membrane,  and  requires  the  regular  treatment  for 
diphtheria,  namely,  antitoxin,  stimulants,  nourishment,  and  local  measures  to  keep 
the  infected  surfaces  clean  and  hasten  removal  of  the  membrane.  It  is  rare,  and 
is  due  to  the  same  cause  as  diphtheritic  vaginitis. 

ECZEMA  OF  VULVA. 

jVesicular  eczema  of  the  vulva  is  most  frequently  located  on  the  labia  majora. 
The  vesicles  break  and  form  crusts,  and  an  itching,  inflamed  discharging  surface 
persists.  Chronic  erythematous  and  squamous  eczema  also  may  occur,  in  which 
case  the  skin  is  infiltrated  and  may  become  nodular.  The  eczema  may  be  limited 
to  the  vulva  or  it  may  extend  to  the  adjacent  cutaneous  surfaces  or  into  the  va- 
gina. 

Causes  and  Symptoms.  The  predisposing  causes  are  the  same  as  predispose  to 
eczema  elsewhere,  namely,  general  nutritive  disturbances  characterized  by  gastro- 
intestinal disorders  or  rheumatism  or  gout.  The  local  nutritive  disturbances  ac- 
companying the  menopause  seem  to  predispose  to  eczema  of  the  vulva.  The  excit- 
ing cause  is  usually  some  local  irritation,  such  as  vaginal  discharge,  diabetic  urine 
and  other  causes  of  irritation  mentioned  under  the  etiology  of  simple  vulvitis. 

The  symptoms  of  eczema  of  the  vulva  are  practically  the  same  as  of  eczema 
elsewhere,  i.  e.,  burning,  itching,  infiltration  and  induration,  with  some  thickening 
of  the  parts  and  frequently  a  discharge. 

Treatment.  The  indications  for  treatment  are  to  allay  the  local  irritation  and 
correct  as  far  as  possible  the  general  nutritive  disturbances,  as  in  the  treatment  of 
eczema  in  other  localities.  Alcoholics,  spices  and  highly  seasoned  foods  must  be 
forbidden.  In  acute  eczema  of  the  vulva,  the  measures  recommended  under  acute 
vulvitis  may  be  employed.  The  lead  and  opium  wash  gives  much  relief,  or  the 
calamine  and  zinc  lotion  (see  Formulae)  may  be  used.  A  soft  cloth  may  be  wet  in 
this  lotion  and  applied  to  the  parts,  being  held  in  place  by  a  T-bandage.  If  the 
irritation  is  marked,'  keep  the  cloth  constantly  wet  with  the  lotion.  Another  way 
of  applying  the  lotion,  where  the  irritation  is  not  so  great,  is  to  mop  it  over  the 
parts  and  allow  it  to  dry  and  form  a  protective  coating. 

As  a  cleansing  agent,  hydrogen  peroxide  is  exceedingly  useful  and  may  be  ap- 
plied in  all  stages  of  the  disease,  either  diluted  with  one  or  two  times  its  volume  of 
water  or  used  full  strength.     Another  excellent  application  in  acute  eczema  of 


ECZEMA  OF  vriAA  409 

this  region  is  the  "black  wash"  (see  Formula?).  This  is  mopped  freely  on.  the 
parts  for  several  minutes  and  then  allowed  to  dry.  It  forms  a  protective  sediment, 
over  which  may  bo  applied  a  sedative  ointment.  This  application  may  be  re- 
peated every  few  houi-s.  During  the  acute  stage,  a  soothing  ointment  such  as  the 
zinc  oxide  and  carl^olic  ointment  (see  Formuhe)  is  useful,  particularly  if  the  pa- 
tient has  to  be  up  and  about,  This  may  be  applied  each  time  after  the  application 
of  one  of  the  lotions  above  mentioned.  Another  useful  application  in  the  acute 
form  is  the  oxi('e  of  zinc  emulsion  in  almond  oil  (see  Formula). 

In  the  subacute  and  chronic  cases,  and  these  are  the  most  frequent,  the  diachylon 
ointment  (equal  parts  of  emplasti-imi  plumbi  and  vaseline  melted  together)  may 
be  used  with  much  benefit.  In  the  more  sluggish  cases,  emplastnun  i)lumlji  un- 
diluted ma}'  be  used.  Cleanse  the  affected  surface  thoroughly  with  green  soap 
and  cotton  lialls,  dry  it  and  then  apply  diachylon  ointment  spread  on  gauze  or 
better  still,  small  strips  of  bandage  muslin.  This  dressing  should  be  held  firmly 
against  the  surface  by  a  T-bandage.  The  ointment  should  be  kept  applied  con- 
tinuously for  several  days,  no  water  being  used  locally  except  what  is  absolutely 
necessary  for  cleanliness.  In  four  or  five  days  the  cleansing  with  gi-een  soap  may 
be  repeated  to  be  followed  by  the  application  of  the  ointment.  If  the  eczematous 
process  is  sluggish  and  more  stimulation  is  required  the  diachylon  plaster  (em- 
plastrum  plumbi)  may  be  used  full  strength,  applied  on  muslin  the  same  as  the 
ointment. 

Tar  ointment  is  still  more  stimulating  to  the  skin  and  sometimes  gives  better 
results  than  the  diachylon  treatment.  It  is  indicated  in  the  dry  scaly  forms  and 
should  be  applied  tentatively  as,  in  some  persons,  it  produces  too  much  irritation. 
Begin  with  a  preparation  containing  a  small  amount  of  tar  (see  Formulae).  If 
this  produces  no  irritation  and  a  stronger  stimulant  is  needed,  the  quantity  of  tar 
may  be  doubled  and  later  quadrupled.  The  tar  ointment  may  be  applied  on 
strips  of  muslin  or  the  patient  may  rub  it  into  the  surface  with  the  fingers.  Some 
think  the  rubbing  in  of  the  ointment  makes  it  more  effective.  Tar  ointment  is  not 
indicated  when  there  is  deep  infiltration.  It  is  most  useful  in  the  superficial 
chronic  scaly  form. 

When  pruritis  is  marked,  the  application  of  hot  water  for  a  short  time,  followed 
by  the  application  of  an  ointment,  sometimes  gives  much  relief.  The  ointment 
to  be  used  should  be  at  hand  ready  for  application.  Then  a  cloth  wet  in  very  hot 
water  is  applied  to  the  involved  area  and  held  there  for  a  few  minutes  until  it  liegins 
to  cool.  The  surface  is  then  dried  with  a  soft  cloth  or  cotton  and  the  ointment 
applied  at  once. 

An  occasional  application  of  silver  nitrate  solution  (4%  to  10%)  is  of  decided 
benefit  in  some  cases. 

In  the  very  chronic  cases,  one  plan  of  treatment  is  to  go  over  the  surface  with  the 
sharp  curet  and,  following  the  curetment,  to  rub  into  the  surface  a  3%  solution  of 
salycilic  acid  in  alcohol. and  then  apply  the  diachylon  ointment  spread  on  muslin. 
In  place  of  the  curet  the  affected  area  may  be  scarified  with  a  knife,  the  scarifica- 
tions being  made  deep  enough  to  cause  considerable  exudate  and  l^leeding,  which 
may  be  further  promoted  by  the  application  of  hot  water  for  a  short  time.     Then 


410  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

the  parts  are  dried  and  the  salycilic  acid  in  alcohol  applied,  followed  by  the  diachy- 
on  ointment. 

INTERTRIGO. 

Intertrigo  is  a  hyperemic  condition  of  the  skin,  with  slight  maceration  and  con- 
sequent irritation.  The  patients  usually  refer  to  it  as  "chafing"  or  "heat."  It 
is  due  to  prolonged  contact  and  friction  of  opposed  surfaces.  The  normal  skin 
secretions  are  retained  between  the  approximated  surfaces  and  become  decomposed 
and  irritating.  It  occurs  most  frequently  in  stout  women  and  in  infants,  because 
in  them  the  skin  surfaces  are  in  contact  more  constantly  and  over  a  wider  area. 
It  is  usually  worse  in  hot  weather  because  the  skin  secretions  are  increased  then, 
and  also  because  the  additional  heat  hastens  decomposition.  Intertrigo  in  this 
region  may  be  caused  or,  if  present,  may  be  made  worse,  by  anything  that  acts  as 
an  irritant  to  the  skin,  for  example,  vaginal  discharge,  uncleanUness  and  the  vari- 
ous etiological  factors  mentioned  under  Acute  Vulvitis. 

The  process  may  affect  any  surfaces  kept  in  apposition.  It  is  usually  located 
in  the  genito-crural  creases,  but  may  spread  inward  over  the  labia  or  outward  over 
the  thighs  and  upward  on  the  abdominal  wall.  At  first,  intertrigo  consists  simply 
of  hyperemia  and  slight  irritation  of  the  skin,  but  after  a  time  there  is  considerable 
serous  and  cellular  infiltration,  with  thickening  and  fissures  and  pigmentation. 
Infection  may  take  place  through  some  of  the  fissures  or  abrasions,  and  the  result 
is  an  acute  inflammation  of  the  skin. 

Intertrigo  gives  rise  to  a  great  deal  of  burning  and  itching  and  discomfort, 
frequently  to  such  an  extent  that  walking  causes  much  distress.  When  the  irri- 
tation is  marked,  there  is  a  serous  secretion  from  the  surface,  which  adds  to  the 
patient's  discomfort  and  to  the  local  irritation  by  soiling  the  adjacent  portions  of 
the  clothing.  Clinically  the  dividing  line  between  intertrigo  and  eczema  is  not 
distinct. 

Treatment.  Secure  cleanliness  by  the  frequent  application  of  the  carbolic  v.^ash 
or  a  strong  solution  of  baking  soda  (tablespoonful  to  a  pint  of  water) .  After  each 
washing,  the  parts  should  be  carefully  dried  and  then  dusted  freely  with  some  dry- 
ing and  antiseptic  powder,  for  example,  the  zinc  oxide  and  magnesium  carbonate 
powder  (see  Formulae).  Other  drying  powders  are  mentioned  under  Acute  ^'ulvitis 
and  also  under  Pruritis  Vulvae.  After  the  application  of  the  powder,  a  piece  of 
cotton  or  gauze  should  be  placed  so  as  to  keep  the  affected  surfaces  from  coming 
in  contact. 

The  cleansing  and  dusting  must  be  done  from  three  to  six  times  daily,  i.  e., 
frequently  enough  to  keep  the  surfaces  clean  and  dry.  If  the  patient  can  rest  in 
bed  for  a  few  days,  the  surfaces  may  be  covered  and  kept  separated  by  pieces  of 
gauze  wet  in  the  calamine  lotion  (see  Formula). 

The  treatment  is  much  more  effective  when  the  patient  can  be  kept  quiet  and 
in  bed.  If  she  is  obliged  to  work  during  the  day,  frequent  washings,  of  course, 
can  not  be  employed,  and  it  is  then  advisable  to  prescribe  a  sedative  ointment 
such  as  the  zinc  oxide  and  carbolic  ointment  (see  Formula^)  to  be  applied  between 
the  applications  of  the  lotion.  The  surfaces  must  be  kept  separated  by  a  soft 
cloth  or  cotton. 


HERPES  OF   VULVA  411 

In  chronic  cases,  some  of  the  stimulating  ointments  mentioned  under  Eczema 
are  beneficial,  lu-zema  may  develop  over  an  area  of  intertrigo,  and  in  that  case 
the  treatment  given  under  Eczema  is  required. 

Ravogli  recommends  the  following  measures  for  intertrigo.  When  the  surface 
is  excoriated  and  there  is  considera])le  secretion,  keep  the  patient  in  bed  and  ap- 
ply Burow's  solution  (see  Formula")  in  strength  of  3%,  on  strips  of  Unt, which  serve 
to  keep  the  sui-faces  apart.  This  usually  causes  the  intertrigo  to  disappear  after  a 
few  applications. 

If  the  patient  must  work,  then  the  bathing  with  the  above  solution  may  take 
place  morning  and  evening,  while  during  the  day  some  sedative  ointment  may  l)e 
applied  to  the  surfaces,  which  should  be  kept  separated  with  soft  lint.  In  chronic 
intertrigo  with  papillary  hypertrophy,  make  two  or  three  applicatioas  of  Wilkin- 
son's ointment  (see  Formula)  which  causes  desquamation  of  the  old  epidermis, 
with  consequent  development  of  new  soft  epidermis.  The  resorcin  and  salicylic 
acid  ointment  (see  Formula?)  has  been  found  effective  in  some  Ccoses. 

To  prevent  relapses,  it  is  well  to  wash  the  creases  in  the  genito-crural  region 
\  er}^  frequently  and  keep  them  dusted  with  starch  powder  containing  2%  of  boric 
acid  or  salicylic  acid,  or  with  some  other  suitable  dusting  powder. 

HERPES  OF  VULVA. 

Herpes  may  occur  on  the  vulva,  where  it  is  known  also  as  "  herpes  progenitalis." 
I'he  vesicles  of  the  herpetic  eruption  are  usually  of  larger  size  than  those  of  vesic- 
ular eczema.  Furthermore,  they  occur  in  gi'oups  and  do  not  rupture  easily, 
whereas  the  vesicles  of  eczema  rupture  spontaneously,  causing  a  sticky  discharge. 
Herpes  is  seldom  accompanied  by  the  intense  burning  and  itching  which  character- 
ize eczema.  Herpes  occurs  especially  in  nervous  women,  particularly  when  there 
is  marked  pelvic  congestion  from  any  cause.  With  some  women  it  occurs  at  nearly 
every  menstrual  period. 

The  discomfort  from  uncomplicated  herpes  is  so  slight  that  not  much  treatment 
is  required.  The  parts  should  be  kept  clean  and  dry  and  may  be  dusted  frequently 
with  some  drying  powder,  for  example,  equal  parts  of  zinc  oxide  and  prepared 
chalk.  All  irritation  should  be  avoided.  If  there  is  troublesome  pruritis  or  burn- 
ing or  smarting,  a  sedative  lotion  or  ointment  may  be  used.  The  erosions  left  by 
rupture  of  the  vesicles  should  not  be  cauterized,  as  it  is  not  necessary  and  may 
cause  deep  ulcers. 

PRURIGO  OF  VULVA. 

This  is  a  rare  disease  of  the  skin,  beginning  usually  in  early  childhood  and  re- 
appearing in  later  life  at  irregular  intervals  and  sometimes  continuing  for  long 
periods.  It  is  characterized  by  a  papular  eruption  and  very  troublesome  itching. 
The  papules  are  at  first  of  the  color  of  the  skin  and  are  more  readily  felt  than  seen, 
giving,  on  palpation,  a  rough  "goose-skin"  sensation.  Later  there  are  various 
secondary  changes  (abrasions,  pigmentation,  desquamation  and  decided  infiltra- 
tion and  thickening)  due  to  the  scratching  excited  by  the  severe  pruritis.  The 
pathology  of  the  disease  is  somewhat  in  doubt,  some  authorities  holding  that  it  is 
a  neurosis  and  others  holding  that  it  is  dilatation  of  the  lymphatics,  causing  irri- 


412  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

tation  of  the  nerve  filaments  of  the  skin.  The  disease  is  usually  limited  to  the  ex- 
tensor surfaces  of  the  arms  and  legs,  the  genitals  being  rarely  affected.  When  it 
does  affect  the  genitals,  it  causes  troublesome  and  persistent  pruritis,  helping  to 
swell  the  Ust  of  cases  of  "pruritis  vulvae." 

In  the  treatment,  the  patient's  general  health  should  be  put  in  the  best  condi- 
tion. The  irritability  of  the  nervous  system  should  be  reduced  by  the  adminis- 
tration of  sedatives,  such  as  bromides  or  cannabis  Indica.  The  pruritis  is  dimin- 
ished in  some  cases  by  tincture  of  cannabis  Indica  by  the  mouth  and  also  by 
pilocarpine  hypodermatically.  Locally,  an  ointment  containing  menthol  or  both 
menthol  and  chloroform,  may  give  much  relief  (see  Formula).  Also  the  salicylic 
acid  and  creosote  ointment  (see  Formulae)  has  proven  useful.  If  the  itching  is 
severe  and  persistent  in  spite  of  the  ointments  mentioned,  cocaine  suppositories 
may  be  used  for  temporary  relief.  The  cocaine  suppository  is  to  be  introduced 
into  the  vagina  when  the  itching  is  severe,  and  as  the  suppository  melts  the  medicine 
becomes  distributed  over  the  affected  surfaces.  Other  remedies  for  the  itching 
may  be  found  under  Pruritis  Vulvae.  Ether  and  alcohol  (1  to  4)  and  also  chloro- 
form and  alcohol  (1  to  4)  have  been  recommended  for  the  purpose  of  dissolving 
out  the  tenaceous  masses  at  the  bottom  of  the  papillae. 

PARASITIC  DISEASES  OF  VULVA. 

The  parasitic  diseases,  pediculosis  and  scabies,  occur  here  as  elsewhere  on  the 
body  surfaces.  They  give  rise  to  much  irritation  and,  unless  search  is  made  for 
the  parasites,  the  patient  may  be  treated  ineffectually  for  a  long  time  for  the 
resulting  pruritis  and  irritation. 

Pediculosis  Pubis. 

This  is  the  most  common  parasitic  disease  of  the  vulva.  The  pediculus  pubis 
or  "crab  louss"  (Fig.  482)  differs  from  the  pediculi  found  on  other  parts  of  the 

body.  It  inhabits  the  pubic  hairy  region  and  may 
give  rise  to  much  irritation.  It  is  conve3^ed  from 
one  person  to  another  by  contact,  usually  in  sexual 
intercourse. 

There  is  itching  and  consequent  scratching,  with 
resulting  abrasions  and  vulvitis.  The  diagnosis  is  made 
by  finding  the  parasites  (Fig.  482),  which  are  attached 
to  the  hairs  near  the  skin.  At  first  they  may  not  be 
noticed,  but  on  close  inspection  they  are  seen  as  small 
Fig.  482.   Tiie  Pediculus  Pubis,      brownish  particles  attached  to  the  hairs  very  close  to 

magnified.   {Stelwagon— Essentials  ,  ,  . 

0/ Skin  Diseases.)  '  tne  SKm. 

The  treatment  is  to  apply  oleate  of  mercury  (10%) 
once  daily,  rubbing  it  well  into  the  hairy  region.  After  the  remedy  has  been 
applied  for  four  or  five  days  it  may  l)e  washed  off,  and  need  not  be  apjilied  again 
unless  there  develop  evidence  that  some  of  the  parasites  escaped  destruction. 
At  the  end  of  the  treatment,  a  soap  and  water  bath  and  complete  change  of  under- 
clothing must  take  place.     An  elegant  and  effective  preparation  used  in  the  same 


SIMPLE  VAGINITIS  413 

way  is  Kapozi's  petroleum  salve  (see  Formulic).  Some  recommend  to  shave  the 
pul)i.s  or  to  clip  the  hair  there,  but  that  is  usually  not  necessary.  If  there  is  much 
local  in-itation  remaining  after  the  parasites  are  killed,  the  measures  given  under 
Simple  ^'ulvitis  may  be  employed. 

Scabies. 

Scabies  may  appear  about  the  external  genitals  as  part  of  an  exteasive  develop- 
ment of  scabies,  the  infection  usually  appearing  first  on  the  fingers.  There  are 
the  usual  symptoms — severe  itching,  worse  when  the  body  is  warm,  and  the 
abrasions  and  irritation  resulting  from  scratching.  The  diagnosis  is  made  by  find- 
ing the  burrows  of  the  itch-mite  on  other  portions  of  the  body,  usually  on  the  fingers. 

The  treatment  consists  of  a  warm  soap-water  batli  followed  by  the  free  use  of  a 
sulphur  ointment  (see  Formulae).  Immediately  after  the  bath,  the  patient  should 
rub  the  ointment  thoroughly  into  all  the  infected  areas,  and  put  on  clean  under- 
clothing. The  inunction  should  be  repeated  night  and  morning  for  three  days, 
the  same  underclothing  and  same  bed  linen  being  used  during  the  course.  On  the 
fourth  day  a  warm  soap  bath  should  be  taken  and  clean  underclothing  put  on.  If 
some  irritation  of  the  skin  remains,  a  mild  ointment,  such  as  zinc  oxide  ointment 
or  carbolized  vaseline,  may  be  used  for  a  few  days.  If  any  of  the  burrows,  con- 
taining the  ascarus  scabiei,  escape  the  first  unction  course,  another  similar  course 
must  be  carried  out. 

SIMPLE  VAGINITIS. 

Simple  vaginitis  is  inflammation  of  the  vagina  due  to  irritation  or  to  the  ordi- 
nary pus  germs.     It  is  known  also  as  "catarrhal  vaginitis." 

Etiology.  The  normal  vaginal  secretion  is  destructive  to  the  ordinary  pus 
germs  and  tends  to  protect  the  vaginal  wall,  as  well  as  the  cervix  uteri,  from  in- 
fection. Anything  that  lowers  the  nutrition  of  the  vaginal  wall  interferes  also 
with  the  protective  action  of  the  vaginal  contents  and  hence  predisposes  to  in- 
flammation. Wasting  diseases  of  every  kind  have  that  effect  to  some  extent, 
but  it  is  especially  noticeable  in  those  conditions  causing  congestion  of  the  vagina, 
such  as  pelvic  tumors,  pelvic  inflammatory  affections,  pregnancy  and  heart  dis- 
ease. In  the  presence  of  any  of  the  predisposing  causes,  and  sometimes  without 
them,  vaginitis  may  be  produced  by  the  following  causes: 

1.  Use  of  an  infected  syringe-nozzle  or  syringe,  carrying  staphylococci  or  strep- 
tococci into  the  vagina.  Ordinarily  these  germs  are  killed  by  the  vaginal  con- 
tents, but  in  cases  in  which  the  nutrition  of  the  vaginal  wall  is  disturbed  and  the 
resistance  consequently  lowered,  these  germs  may  multiply  rapidly  and  cause 
severe  vaginitis. 

2.  An  infective  uterine  discharge,  for  example,  in  acute  septic  endometritis. 

3.  Decomposition  of  a  chronic  uterine  discharge.  Ordinarily  a  chronic  dis- 
charge from  the  uterus  passes  out  of  the  vagina,  causing  only  slight  irritation,  but 
if  it  is  retained  long  in  the  vagina,  decomposition  takes  place,  causing  marked 
irritation  and  vaginitis. 

4.  Use  of  strongly  irritating  substances  in  the  vagina,  for  example,  where  a  too 


414  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

concentrated  douche  solution  is  used  by  mistake,  or  where  some  irritating  sub- 
stances are  introduced  into  the  vagina  for  the  purpose  of  causing  an  al^ortion. 

5.  Foreign  bod}^  in  the  vagina.  A  pessar}^  worn  too  long  or  without  proper  pre- 
caution may  cause  severe  local  vaginitis,  extending  even  to  ulceration.  In  some 
cases  of  this  character  it  has  happened  that  the  ulceration  has  extended  deeply  into 
the  vaginal  wall.  Kelly  illustrates  a  case  in  which  ulceration  took  place  with  so 
much  resulting  cicatricial  contraction  below  the  pessary,  that  the  vagina  was 
occluded  and  a  collection  of  pus  formed  above  the  point  of  occlusion.  Foreign 
bodies  introduced  for  the  purpose  of  masturbation  are  liable  to  cause  vaginitis. 

6.  In  sexual  intercourse,  germs,  other  than  the  gonococcus,  may  be  carried  into 
the  vagina,  and,  if  the  soil  is  favorable,  simple  vaginitis  will  result.  Again*,  slight 
traumatisms  in  difficult  coitus  furnish  an  entrance  for  germs,  with  resulting  vagin- 
itis. 

7.  In  the  exanthemata — measles,  scarlet  fever  and  the  other  eruptive  diseases — 
the  eruptive  disturbance  may  extend  to  the  vagina,  causing  much  irritation  and, 
as  a  consequence,  vaginitis. 

Pathology  and  Symptoms.  The  inflammatory  phenomena  are  the  same  as  in 
gonorrhoeal  vaginitis,  except  not  so  marked.  The  vaginal  walls  present  active 
congestion.  They  are  red  and  hot,  and  manipulations  cause  pain.  At  first  the 
secretion  is  slight,  but  very  soon  it  is  increased  and  becomes  purulent.  There 
is  a  serous  and  cellular  exudate  into  the  vaginal  wall  and  the  superficial  layers  of 
epithelium  are  thrown  off  and  form  part  of  the  discharge. 

In  chronic  cases  the  acute  symptoms  have  disappeared  but  the  cellular  infiltra- 
tion and  epithelial  exfoliation  persist.  The  papillae  may  become  especially  swol- 
len, giving  the  sensation  of  a  rough  granular  surface.  The  lor.ger  the  process  con- 
tinues, the  deeper  the  infiltration  extends. 

In  acute  vaginitis  usually  the  first  symptoms  are  dryness,  heat  and  itching  in 
the  vagina  and  about  the  vulva.  Later,  a  discharge  appears  with  consequent  ii-ri- 
tation  about  the  vaginal  orifice  and  the  meatus.  The  valvar  irritation  and  the 
urinary  disturbance  are  usually  not  nearly  so  marked  as  in  gonorrhoea.  General 
disturbances  are  slight.  The  patient  feels  somewhat  feverish,  but  decided  rise 
of  temperature  is  rare,  and  when  present  should  arouse  suspicion  of  complications. 

Diagnosis.  The  fact  that  the  vagina  is  inflamed  can  be  directly  demonstrated 
m  the  examination,  so  it  remains  onl}^  to  distinguish  simple  vaginitis  from  the 
other  forms  of  vaginal  inflammation.. 

Gonorrhoeal  Vaginitis  is  distinguished  by  the  following: 

a.  Inflammation  is  rapid  in  development  and  severe. 

b.  Involvement  of  urethra  and  vulvo-vaginal  glands. 

c.  No  other  apparent  cause. 

d.  Gonococci  in  the  discharge. 

e.  History  of  suspicious  coitus  within  a  few  days  before  the  beginning  of  the 
trouble.  In  exceptional  cases  a  simple  vaginitis  may  give  rise  to  a  simple  ure- 
thritis in  the  husband.  But  simple  vaginitis  never  gives  rise  to  a  gonorrhoeal  ure- 
thritis, as  some  husbands  endeavor  to  make  out. 

Diphtheritic  Vaginitis  is  distinguished  by: 

a.  Development  of  a  false  membrane  on  the  vaginal  wall. 


SIMPLE  VAGINITIS  IN  CHILDREN  415 

b.  Marked  systemic  effects. 

c.  Presence  of  diphtheria  bacilli,  as  demonstrated  by  bacteriological  examina- 
tion. 

Adhesive  Vaginitis  presents  the  following  characteristics: 

a.  Inflammation  is  only  chronic  or  subacute. 

b.  Occurs  in  patches,  resembling  abraded  areas. 

c.  Walls  of  vagina  adhere,  and  separation  of  the  adhesions  causes  a  bloody  dis- 
charge. 

d.  Patient  is  usually  past  the  menopause. 

Treatment.  In  the  severe  cases  the  same  treatment  is  indicated  as  in  gonor- 
rhoeal  vaginitis.  Usually,  however,  the  inflammation  is  comparatively  mild,  and 
an  antiseptic  douche,  such  as  bichloride  1-5000,  two  or  three  times  daily,  is  all  that 
is  required.  The  cause  must  be  sought  and  removed,  for  example,  if  it  is  due  to 
an  irritating  discharge  from  the  uterus,  the  uterine  lesion  must  receive  appropriate 
treatment.  If  the  vaginitis  becomes  chronic,  the  treatment  described  under 
Chronic  Gonorrhoeal  Vaginitis  should  be  employed. 

Simple  Vaginitis  in  Children. 

In  children  a  troublesome  discharge  sometimes  appears  and  gives  rise  to  much 
vulvar  irritation.  The  trouble  is  frequently  not  severe  enough  to  be  called  inflam- 
mation of  the  vagina — there  seems  to  be  simply  an  excess  of  secretion,  causing  a 
vaginal  discharge.  But  the  vulvar  irritation,  which  is  the  most  marked  symptom, 
often  necessitates  measures  to  stop  the  excessive  secretion.  The  treatment  of 
this  affection  consists  in  keeping  the  external  genitals  clean  and  dry  by  washing 
frequently  with  a  weak  carbolic  solution,  then  drying  with  absorbent  cotton  and 
then  dusting  with  a  drying  powder,  such  as  boric  acid  powder.  Bismuth  subnitrate 
and  prepared  chalk,  equal  parts,  is  also  a  good  dusting  powder.  Keep  the  vulva 
covered  with  a  pad  of  absorbent  cotton. 

The  child  should  be  put  in  first-class  general  health.  Often  the  patient  presents 
lowered  vitality  and  anemia  and  a  general  relaxation  or  want  of  tone  in  the  tissues 
— the  so-called  strumous  diathesis.  In  such  a  case,  a  course  of  tonic  treatment, 
restoring  the  patient's  vitality,  will  often  cause  the  discharge  to  cease.  If  the  dis- 
charge persists,  a  mildly  astringent  vaginal  suppository  may  be  introduced  into 
the  vagina  once  daily  (see  Formulae). 

Of  course,  in  severe  vaginitis  in  children,  the  vagina  should  be  irrigated,  muck 
the  same  as  in  adults,  but  in  the  mild  disturbance  here  described  vaginal  irrigation 
is  rarely  necessary.  When  it  is  necessary,  the  vagina  may  be  carefully  washed  out 
once  or  twice  daily  with  the  carbolic  or  other  douche  solution,  using  a  small  soit- 
rubber  catheter  instead  of  the  ordinary  douche-nozzle. 

PARASITIC  VAGINITIS. 

Parasitic  vaginitis  is  the  term  applied  to  inflammation  of  the  vagina  due  to  the 
same  fungus  which  causes  thrush  in  the  mouth.  It  is  known  also  as  "mj'cotic 
vaginitis"  and  as  "aphthous  vaginitis." 

The  cause  is  invasion  of  the  vagina  by  parasites  of  the  order  of  oidium  albicans, 


41(3 


DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 


or,  perhaps  more  correcth',  saccharomyces  albicans.  The  infection  is  carried  to 
the  genitals  usually  by  the  fingers  of  the  patient,  who  has  been  handling  some  or- 
ganic substance  on  which  the  fungus  was  gi-owing.  A  mother  whose  baby  is  suft'er- 
ing  with  thrush  may  infect  herself.  It  usually  occurs  in  nursing  women  or  in  preg- 
nant women  or  in  cases  of  prolapsus  uteri.  •  It  is  said  to  occur  sometimes  as  the 
result  of  sexual  intercourse  with  a  diabetic  husband. 

The  pathological  changes  are  practically  the  same  as  in  thrush  in  the  mouth. 
There  are  white  patches,  representing  the  growing  fungus,  and  accompanying  in- 
flammation of  the  adjacent  tissues.  The  patient  complains  of  burning,  itching  or 
smarting,  but  there  is  not  much  discharge.  In  the  examination  through  the  specu- 
lum, the  vaginal  wall  presents  thei©rdinary  e\adences  of  inflammation  and  in  ad- 
dition it  is  studded  "^dth  small  white 
patches  about  the  size  of  a  pin-head. 
In  some  cases  small  ulcers  may  form. 
A  scraping  from  one  of  the  white 
patches,  examined  with  a  microscope, 
will  show  the  fungus  (Fig.  483). 

Treatment.    Douches  will  give  some 

relief,    but  must  be  supplemented  by 

application  through   the  speculum  of 

a  more  concentrated   antiseptic,  such 

as  argja-ol  25%  or  protargol   10%  or 

silver  nitrate  5%  or  bichloride  solution 

(1-500).     After  the  appHcation,  du.st 

powdered  borax  into  the  vagina  and 

then  introduce  a  tampon  wet  in  50% 

boroglyceride.      Such  treatment,  given 

every    day   or    every    other  day    for 

several  days,  usually  stops  the  disease  promptly.     After  the  fungus  has  been  de-- 

stroj'^ed,  mild  antiseptic  douches  are  required  for  a  time  for  the  accompanying 

simple  vaginitis. 


Fig.  483.     The  Thnisli  Fungus,  under  the  micro- 
scope.    (Holt — Diseases  of  Children.) 


DIPHTHERITIC  VAGINITIS. 

This  form  of  vaginitis  is  due  to  infection  of  the  vaginal  wall  by  diphtheria  bacilli. 
It  is  rare.  It  is  liable  to  occur  when  there  is  diphtheria  in  the  house,  if  there  are 
nbrasions  of  the  vagina,  particularly  after  labor. 

Diphtheritic  vaginitis  is  characterized  by  the  development  of  a  false  membrane 
over  the  abraded  areas  and  by  the  marked  systemic  effects  of  diphtheria,  in  ad- 
dition to  the  usual  signs. of  vaginitis.  Streptococci  sometimes  cause  a  membrane. 
The  differential  diagnosis  is  made  by  the  surrounding  inflammation  and  the  sys- 
temic disturbances  in  the  two  diseases,  and  especially  by  a  bacteriological  examin- 
ation when  that  is  available. 

The  treatment  should  include  the  measures  recommended  for  simple  vaginitis, 
and,  in  addition,  antitoxin  and  other  remedies  indicated  in  diphtheria. 


ADHESIVE  VAGINITIS 


417 


EMPHYSEMATOUS  VAGINITIS. 

In  emphysematous  vaginitis,  small  collections  of  gas  appear  under  the  epithe- 
lium or  in  the  meshes  of  the  connective  tissues.  It  is  a  rare  form  of  vaginal  in- 
flammation and  occurs  almost  exclusively  in  pregnant  women.  Its  seat  is  the  up- 
per part  of  the  vagina  and  the  vaginal  portion  of  the  cervix.  The  little  air  vesicle? 
are  close  set  and  vary  from  the  size  of  a  pin  head  to  several  times  as  large.  They 
are  frequently  surrounded  by  an  area  of  hyperemia,  but  the  inflammatory  reaction 
is  slight.  When  punctured  the  air  escapes  and  the  vesicle  collapses.  There  is 
rarely  any  secretion  from  them.  The  gas  contained  in  them  is,  in  part  at  least, 
trimethylamine.  The  vesicles  show  little  tendency  to  reform  after  puncture. 
The  affection  is  du€  to  a  mild  gas-producing  bacillus.  But  it  apparently  bears  no 
relation  to  infection  with  the  gas-forming  bacillus  known  as  the  bacillus  aerogenes 
capsulatus,  for  this  deadly  germ  gives  rise  to  a  severe  and  rapidly  spreading 
phlegmonous  inflammation. 

As  to  the  treatment  of  emphysematous  vaginitis,  nothing  more  is  usually  required 
than  puncturing  the  air  vesicles  and  washing  of  the  vicinity  with  an  antiseptic  so- 
lution. If  there  is  an  irritating  discharge,  mild  antiseptic  douches  may  be  given. 
If  the  patient  is  pregnant,  great  care  must  be  exercised  not  to  cause  much  irrita- 
tion, as  an  abortion  might  result. 

ADHESIVE  VAGINITIS. 

Adhesive  vaginitis  is  the  term  given  to  that  form  of  vaginal  inflammation  in 
which  there  is  a  tendency  of  the  opposed  surfaces  to  become  adherent.  It  occurs 
almost  exclusively  in  women  past  the  menopause,  hence  the  name  "senile  vagin- 
itis" by  which  it  is  often  designated.  Occasionally  it  occurs  in  children.  The 
predisposing  cause  in  most  cases  is  the  disturbance  of  nutrition  due  to  old  age. 
The  exciting  cause  is  probably  a  slight  uterine  discharge,  which  macerates  the 
vaginal   epithelium   and  produces  considerable  irritation.     A  certain    amount   of 


Fig.  484.  Indicating  the  condition  in  an  area  of  Adhesive 
Vaginitis.  The  epithelium  is  thrown  off.  The  granulating  surface 
left  may  unite  with  a  similar  area  on  the  opposite  wail,  causing  ad- 
hesions as  described.      (Bnesky—  Diseases  of  Vagina.) 

senile  vaginitis  is  very  frequent  and  often  produces  no  symptoms.  In  fact  it  is 
probable  that  only  a  small  proportion  of  women  over  sixty  are  entirely  free  from 
some  disturbance  of  this  kind,  with  slight  adhesions  here  and  there. 

Over  irregular  patches  the  superficial  layers  of  epithelium  are  thrown  off  (Fig. 
484) ,  forming  erosions  from  which  there  is  a  scanty  secretion.  The  eroded  areas 
are  tender  and  usually  bleed  on  manipulation. 


418  DISEASES  OF  EXTERNAL  GEXITALS  AND  VAGINA 

When  such  areas  develop  on  opposed  surfaces  of  the  vaginal  walls,  adhesions 
take  place  between  them.  For  a  long  time  the  adhesion  is  weak  and  the  surfaces 
may  be  easily  separated.  If  the  process  of  adhesion  is  allowed  to  go  on  undis- 
turbed, the  adhesions  become  organized  and  firm,  and  in  the  course  of  time  maj^ 
become  so  extensive  and  strong  that  the  vagina  is  practically^  obliterated.  Adhe- 
sive vaginitis  is  accompanied  by  a  slight  ''gluey"  discharge,  small  in  amount  but 
irritating. 

The  symptoms  are,  vaginal  discharge,  sometimes  bloody,  ^ith  some  pain  in  the 
pelvis  and  vaginal  burning  and  discomfort.  There  may  be  some  burning  or  smart- 
ing on  urination,  from  irritation  of  the  vulva  by  the  discharge. 

On  digital  examination,  the  vaginal  walls  are  felt  adherent  in  places,  especially 
at  the  upper  portion  of  the  vagina,  and  the  separation  of  the  walls  causes  some  pain 
and  bleeding.  Examination  of  the  vagina  through  the  speculum  shows  hemor- 
rhagic areas  of  denudation  and  inflammation,  principally  in  the  upper  part  of  the 
vagina. 

Diagnosis.  The  evidences  of  subacute  vaginitis  with  marked  tendency  to  ad- 
hesion of  the  walls  in  spots,  establishes  the  diagnosis  of  adhesive  vaginitis.  Vagin- 
itis occurring  after  the  menopause  is  usually  of  this  form.  Be  careful  to  distin- 
guish gonorrhoeal  vaginitis  from  the  ordinary  adhesive  vaginitis.  Serious  disease 
of  the  uterus  causing  discharge,  particularly  cancer,  must  be  excluded. 

Treatment.  If  the  trouble  is  slight  and  causing  no  symptoms,  it  needs  no  treat- 
ment. The  adhesions  in  themselves  cause  no  trouble  and  consequently"  need  no 
treatment. 

When  the  disturbance  gives  rise  to  an  imtating  discharge  or  to  bleeding  or  to 
pain,  then  the  following  treatment  is  indicated: 

1.  Put  the  patient  in  the  best  possible  general  health. 

2.  Keep  the  vagina  free  from  the  irritating  discharge  by  the  use  of  a  mild 
antiseptic  douche,  such  as  the  carbolic  douche,  two  or  three  times  daily.  If  the 
parts  are  atonic  and  show  a  marked  tendency  to  bleed,  an  astringent  douche,  such 
as  the  alum  and  zinc  sulphate  douche  (see  Formulae)  may  be  used. 

3.  Every  second  or  third  or  fourth  day,  depending  on  the  severity  of  the 
vaginitis,  make  a  vaginal  application  of  some  astringent  and  antiseptic,  for 
example,  arg^-rol  25*^  or  protargol  5%  to  10^.  This  should  be  applied  thoroughly 
to  all  parts  of  the  vaginal  wall  involved  in  the  inflammatory  process.  If  the  hemor- 
rhage tendency  is  marked,  an  application  more  strongly  astringent,  such  as  copper 
sulphate  solution  (109c)  ^^Y  be  used. 

After  the  application,  some  measure  should  be  employed  to  keep  the  vaginal 
walls  separated,  at  least  for  a  time.  For  this  purpose  we  may  use  cotton  tampons 
or  gauze  strips  soaked  in  carbolized  glycerine  (2%)  or  covered  with  carbolized  zinc 
oxide  ointment  (2%  to  5%),  or  the  ointment  may  be  spread  on  the  vaginal  walls 
and  then  the  tamjpons  introduced.  Carbolized  olive  oil  (2% to  5%)  makes  a  sooth- 
ing application  to  the  vaginal  walls  and  prevents  adhesion  of  the  opposed  surfaces. 
In  very  sensitive  cases,  either  almond  oil  or  ungentum  aquae  rosae  may  give  more 
relief  than  the  other  remedies  mentioned.  For  use  at  home,  between  the  office 
applications,  astringent  vaginal  suppositories  (see  Formulae)  are  sometimes 
beneficial. 


SIMPLE  ULCER  4](j 

4.  The  exciting  cause  of  the  trou])le  must  be  sought  and,  if  possible,  removed. 
Frequently  it  will  be  found  to  be  an  irritating  discharge  tlue  to  senile  endome- 
tritis, which  must,  of  course,  receive  appropriate  treatment. 

SIMPLE  ULCERS 

OK  N'l'LVA    AND   \'A(II\A. 

Ulcers  or  ulceration  of  the  vulva  or  vagina  may  indicate  the  following  condi- 
tions: 

1.  Simple  irritation  or  pus  infection.  Any  of  the  nunicrous  irritants  that  cause 
vulvitis  may  cause  one  or  more  ulcers,  as  may  also  infection  at  any  point  with 
ordinary  pus  germs. 

2.  Chancroidal  infection. 

3.  Syphilis. 

4.  Tuberculosis. 

5.  ^Malignant  disease. 

6.  Ulcus  rodens  vulvae. 

Those  coming  in  the  first  class  constitute  the  simple  ulcers. 

Pathology  and  Symptoms.  The  simple  ulcers  are  the  ones  considered  here — the 
other  varieties  will  be  taken  up  later.  The  essential  feature  of  an  ulcer  is  that  the 
epithelial  coat  is  lost  down  to  the  connective  tissue,  the  base  being  covered  with 
granualtion  tissue  or  a  slough.  The  infecting  germs  lie  in  the  tissues  close  to  the 
surface  of  the  ulcer,  and  outside  them  is  a  limiting  zone  of  round-cell  infiltration. 
There  is  more  or  less  discharge  from  the  surface  of  the  ulcer,  and  it  usually  bleeds 
on  slight  manipulation.  These  characteristics  pertain  to  all  varieties  of  ulcer. 
There  is  some  pain  and  tenderness  about  the  ulcer,  and  the  discharge  may  cause 
considerable  initation.  If  the  ulcer  is  situated  so  that  the  urine  flows  over  it,  the 
patient  may  experience  smarting  and  burning  on  urination. 

Diagnosis.  The  diagnosis  of  ulcer  presents  no  difficulties,  as  it  is  established 
by  finding  an  area  devoid  of  epithelial  covering  and  presenting  a  granulating  sur- 
face. An  eroded  area  on  the  vulva  or  in  the  vagina,  which  is  sensitive  and  bleeds 
easily,  may  l^e  mistaken  for  an  ulcer,  but  close  inspection  will  show  that  the  surface 
is  still  covered  with  a  thin  layer  of  epithelium. 

The  diagnosis  of  the  variety  of  ulcer  present  is  very  important  and  sometimes 
difficult.  From  simple  ulcer  there  must  be  distinguished  the  chancroidal,  the 
syphilitic,  the  tubercular  and  the  malignant  ulcer. 

The  chancroidal  ulcer  presents  a  ragged  or  irregular  base  with  punched  out  or 
undermined  edges,  and  a  tendency  to  spread  and  also  to  infect  surfaces  with  which 
the  secretion  comes  in  contact  (Fig.  218).  The  chancroidal  ulcer  appears  within 
a  few  days  after  suspicious  coitus.  It  is  tender  and  sometimes  quite  painful,  and 
is  liable  to  be  accompanied  with  painful  inguinal  adenitis,  in  which  the  glands 
become  matted  together  and  later  suppurate. 

There  is  no  marked  induration  underlying  the  sore — it  is  a  "soft  sore."  On 
account  of  the  infective  character  of  the  secretion,  other  ulcers  appear,  and  fre- 
quently the  ulcers  of  the  vulva  are  complicated  by  ulcers  about  the  anus.     It 


420  DISEASES  OP  EXTERNAL  GENITALS  AND  VAGINA 

often  happens  that  these  lesions  about  the  anus  give  rise  to  more  troublesome 
symptoms  than  the  vulvar  ulcers  and  are  really  what  causes  the  patient  to  seek 
relief. 

Syphilitic  ulcers  are  of  two  kinds,  the  primary  lesion,  called  also  "chancre"  or 
"hard  sore,"  and  the  deep  tertiary  ulcers.  The  characteristic  primary  sore  of 
syphilis  becomes  apparent  two  to  four  weeks  after  suspicious  coitus.  It  is  small 
and  not  particularly  painful,  but  presents  an  underlying  area  of  induration  which 
feels  to  the  examining  fingers  as  though  a  small  piece  of  stiff  paper  were  lying  be- 
neath the  ulcer.  The  inguinal  adenitis,  which  appears  after  a  short  time,  is  prac- 
tically painless  and  there  is  no  tendency  to  suppuration  nor  to  matting  together 
of  the  glands.  However,  the  primary  sore  is  seldom  so  distinctly  characteristic 
that  it  is  justifiable  to  begin  constitutional  treatment  before  secondary  manifest-* 
ations  confirm  the  diagnosis.  The  superficial  secondary  lesions,  which  about  the 
vulva  appear  as  flat  condylomata,  are  not  really  ulcers  but  simply  erosions.  The 
ulcers  appearing  in  the  later  stages  of  syphilis  are  usually  ragged,  irregular,  in- 
dolent and  persistent,  and  there  are  other  evidences  of  syphilis.  In  a  doubtful 
case,  a  course  of  potassium  iodide  may  assist  in  clearing  up  the  diagnosis. 

By  a  bacteriologic  examination  of  a  piece  of  tissue  excised  from  the  lesion, 
a  positive  diagnosis  may  be  made  at  once,  in  the  primary  or  secondary  or  tertiary 
stage  of  the  disease  (see  under  Syphilis,  page  427). 

In  tubercular  ulcer  there  may  be  other  organs  presenting  tuberculosis.  Also 
the  nature  of  the  ulcer  is  indicated  by  its  appearance,  by  finding  tubercle  bacilli 
in  the  discharge  or  scrapings  and,  if  still  doubtful,  by  the  examinations  of  sections 
of  tissue  from  the  margin  of  the  sore. 

In  malignant  ulcer,  that  is,  an  ulcer  due  to  the  breaking  down  of  tissue  infiltrated 
with  carcinoma  or  sarcoma  cells,  there  is  a  surrounding  area  of  induration,  rep- 
resenting that  portion  of  the  malignant  infiltration  which  has  not  yet  broken  down. 
A  malignant  ulcer  is  chronic  and  bleeds  easily,  and  the  tendency  to  bleed  is  not 
checked,  but  rather  increased,  by  the  application  of  10%  copper  sulphate  solu- 
tion. In  the  case  of  a  chronic  ulcer  of  doubtful  character,  a  piece  of  the  margin 
of  the  ulcer  should  be  excised  for  microscopic  examination.  Carcinoma  in  this 
situation  causes  death  in  about  two  years.  To  remove  the  growth  completely, 
the  operation  must  be  performed  in  a  very  early  stage,  hence  the  importance  of 
an  early  diagnosis. 

Treatment.  The  first  efforts  in  the  treatment  of  any  ulcer  of  the  external  geni- 
tals should  be  directed  toward  securing  cleanliness  and  allaying  irritation,  liy  the 
measures  recommended  under  Acute  Vulvitis.  In  simple  ulcer,  after  cleansing 
with  carbolic  or  bichloride  solution  and  drying  with  absorbent  cotton,  the  patient 
may  apply  an  antiseptic  ointment,  such  as  carbolized  vaseline  (1%)  or  the  chlore- 
tone  ointment  (see  Formula?).  This  cleansing,  followed  by  the  application  of  the 
ointment,  may  be  carried  out  two  or  three  times  daily  by  the  patient  at  home,  or 
more  frequently  if  there  is  much  discharge.  A  very  efficient  cleansing  application 
for  the  patient's  use  is  hydrogen  peroxide.  Every  second  or  third  day  apply  some 
astringent,  such  as  protargol  (10%)  or  silver  nitrate  solution  (10%)  or  copper 
sulphate  solution  (10%),  to  all  portions  of  the  surface  of  the  ulcer,  and  after 
that  an  astringent    antiseptic    powder.     The    genitals   should    be   kept    covered 


CHANCROID  421 

with  a  piece  of  absorljcnt  cotton  held  in  place  by  a  T-bandap;e.  If  there  is  an  ac- 
companying vaginal  discharge,  the  i)atient  should  take  an  antiseptic  douche  one 
to  three  times  daily.  If  these  cleansing  and  antiseptic  measures  do  not  cause 
the  ulcer  to  heal  promptly,  it  is  probably  not  a  simple  ulcer  but  belongs  to  one  of 
the  special  varieti-es. 

CHANCROID 

OF  Vulva  and  A'agina. 

Chancroid  is  an  infectious  ulcer,  entireh'  local  in  its  effects  and  due  to  inocula- 
tion with  secretion  from  another  chancroid.  It  is  known  also  as  "soft  chancre" 
and  as  "soft  sore."  It  constitute  sone  of  the  three  so-called  "venereal  diseases" 
(gonorrhoea,  chancroid,  syphilis). 

It  is  due  to  a  specific  infectious  agent  which  causes  chancroid  and  nothing  else. 
It  is  invariabh'  due  to  contact  with  virus  from  another  chancroid,  and  sexual 
intercourse  is  nearly  always  responsible  for  this  contact. 

The  infectious  principle  of  chancroid  is  much  more  exclusively  conveyed  by 
sexual  intercourse  than  syphilis.  Converseh'',  chancroidal  virus  is  much  less  liable 
than  syphilitic  virus  to  be  coveyed  in  an  active  state  simply  by  contaminated 
articles.  However,  such  method  of  conveyance  is  probably  possible  and  must  be 
guarded  against.  The  chancroidal  virus  does  not  penetrate  healthy  epithelium  but 
makes  its  entrance  through  a  crack  or  abrasion. 

The  infectious  agent  is  a  short  bacillus,  discovered  by  Ducrey  and  hence  desig- 
nated as  the  Ducrey  bacillus.  It  occurs  in  the  discharge,  but  cannot  be  satis- 
factorily identified  there  because  of  contaminating  material.  For  diagnostic 
examination  a  tissue=specimen  should  be  secured. 

In  the  case  of  enlarged  glands,  the  serum  secured  by  puncture  with  a  large 
hollow  needle  is  usually  satisfactory  for  diagnostic  examination. 

Pathology. 

Within  twenty-four  to  forty-eight  hours  after  infection,  there  appears  a  small 
pustule  on  an  inflammatory  base.  This  point  of  infection  may  be  situated  at  any 
part  of  the  external  genitals  or  in  the  vagina.  This  beginning  lesion  may  not  be 
noticed  by  the  patient,  so  that  according  to  her  statement  the  lesion  may  not  have 
appeared  for  several  days  or  a  week  after  coitus.  In  a  short  time  the  epithelial 
covering  over  the  infected  spot  is  lost  and  a  small  ulcer  is  thus  formed.  This  ulcer 
has  sharp,  punched-out  margins,  a  rough  and  sometimes  necrotic  base,  is  sun-ounded 
by  a  red  inflammation  zone  and  is  accompanied  by  more  or  less  inflammatory 
edema.  In  cases  of  long  standing  or  of  much  inflammation,  there  may  be  con- 
siderable round-cell  infiltration  and  induration  around  the  ulcer  and  under  it,  but 
there  is  rarely  if  ever  the  marked  parchment-like  or  cartilage-like  induration  that 
develops  under  the  primary  lesion  of  syphilis. 

Usually  the  ulcer  gradually  enlarges  and  deepens,  the  destruction  as  a  rule  being 
more  rapid  and  extensive  in  the  vagina  than  on  the  external  surface.  During  this 
stage  the  base  of  the  ulcer  usually  shows  sloughing  tissue  or  false  membrane,  and 
the  surrounding  inflammatory  zone  is  marked.     Alcoholic   drinks,  friction  from 


422  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

exercise  and  also  uncleanliness,  increase  and  prolong  the  destructive  action. 
Ordinarily  after  several  days,  the  time  depending  somewhat  on  the  patient's 
habits  and  general  health,  the  ulcer  shows  a  tendency  to  heal.  Under  treatment, 
the  base  clears  off  and  shows  apparently  healthy  granulation  tissue,  the  surround- 
ing inflammatory  zone  grows  less  and  the  secretion  becomes  more  like  ordinary 
pus.  Gradually  the  gi^anulating  surface  is  replaced  by  a  thin  layer  of  scar,  which 
begins  at  the  margin  and  progi-esses  towards  the  center.  The  usual  duration  of  a 
chancroid  is  two  to  three  weeks.  A  relapse  may  occur  at  any  stage  of  the  healing 
process  and  even  when  apparently  healed,  the  lesions  are  for  some  time  infectious. 
Such  is  the  regular  course  of  a  chancroidal  ulcer,  but  several  other  conditions 
may  develop,  as  follows: 

a.  In  chronic  alcoholics  and  other  subjects  of  diminished  resistance,  the  ulcer 
may  present  ragged  and  undermined  edges  and  becomes  very  destructive  and 
rapid  in  its  advancement,  constituting  what  is  known  as  a  phagedenic  chancroid. 

b.  Any  surface  which  lies  against  a  chancroid  is  liable  to  develop  a  secondary 
chancroid  at  the  point  of  contact,  after  sufficient  time  for  the  irritating  discharge 
from  the  primary  chancroid  to  cause  an  erosion  and  thus  open  an  avenue  for  in- 
fection. Again,  if  pus  from  a  chancroid  comes  in  contact  with  a  scratch  or  abra- 
sion in  the  vicinity,  it  causes  another  chancroid. 

This  is  called  auto-inocculation  and  it  is  one  of  the  marked  characteristics  of 
chancroidal  lesions  in  contra-distinction  to  the  syphilitic  chancre.  It  is  also  one 
of  the  strong  proofs  of  the  purely  local  character  of  chancroid.  On  account  of 
this  property,  chancroids  are  usually  multiple.  There  may  be  two  or  three  or 
there  may  be  many  (Fig.  218).  Frequently  the  secretion  runs  down  over  the  anus, 
where  it  comes  in  contact  with  abrasions  and  causes  chancroidal  ulcers  that  are 
more  painful  than  the  vulvar  lesions.  Sometimes  the  infective  secretion  pene- 
trates the  hair  follicles  or  sebaceous  glands  of  the  vulva,  forming  small  round  sores 
called  follicular  ulcers. 

c.  Not  infrequently  the  virus  is  carried  by  the  lymphatics  to  the  inguinal  glands 
and  there  causes  chancroidal  bubo  which  usually  suppurates  and  gives  rise  to 
a  discharge,  which  is  as  infective  as  that  from  the  original  ulcer.  Of  course,  ordi- 
nary pus  germs  accompany  chancroidal  inflammation,  and  the  ordinary  pus  germs 
may  cause  a  simple  bubo,  not  containing  any  chancroidal  virus.  Such  a  bubo 
would  not  of  course  be  a  chancroidal  bubo,  but  would  be  a  simple  bubo  accompany- 
ing a  chancroidal  ulcer.  It  is  not  settled  just  what  proportion  of  buboes  are  of 
this  class. 

d.  It  sometimes  happens  that  syphilitic  infection  takes  place  at  the  same  time 
as  the  chancroidal  infection  or  just  before  it  or  after  it.  This  constitutes  a  mixed 
infection  which  not  infrequently  causes  a  mistake  in  diagnosis  and  much  chagi-in 
on  the  part  of  the  physician,  who  sees  unmistakable  evidences  of  syphilis  develop 
from  a  sore  which  he  had  pronounced  simply  a  chancroid.  For  the  first  two  or 
three  weeks  there  may  be  nothing  to  indicate  that  syphilitic  infection  has  taken 
place,  but  after  that  time  the  ulcer,  instead  of  cicatrizing  as  a  chancroid  should 
do,  develops  the  induration  and  other  charatceristics  of  a  syphlitic  sore.  This 
mixed  infection  occurs  rather  frequently  and  its  'possibility  in  any  particular  case 


DIAGNOSIS  OF  CHANCROID 


123 


must  be  kept  in  mind,  that  due  caution  may  be  exercised  in  giving  the  diagnosis 
and  prognosis. 

Symptoms. 

There  may  be  few  or  no  symptoms,  except  when  the  ulcer  is  touched  or  rubl^ed 
by  the  clothing.  In  some  cases  the  patient  complains  only  of  a  discharge  and 
smarting  on  urination.  She  may  be  unaware  that  any  sore  is  present  on  the  jreni- 
tals.  On  the  other  hand,  the  patient  may  complain  of  much  itching  and  of  other 
symptoms  of  acute  vulvitis  due  to  the  irritating  discharge.  If  the  ulcer  is  so  situ- 
ated that  the  urine  flows  over  it,  there  is  usually  considerable  smarting  and  pain 
on  urination.  When  situated  in  the  vagina,  the  ulcer  gives  rise  to  an  irritating 
discharge,  frequently  blood-streaked,  and  also  to  other  symptoms  of  vaginitis. 

In  multiple  chancroids,  the  discomfort  is  accordingly  increased,  and  in  phage- 
denic chancroid  the  general  health  may  be  seriously  impaired.  In  chancroids  about 
the  anus,  there  is  much  pain,  particularly  on  defecation,  and  occasionally  the  ex- 
cruciating pain  of  anal  fissure  appears. 

If  infection  of  the  lymphatic  glands  takes  place  the  patient  complains  of  pain  in 
the  affected  gi'oin,  increased  by  walking,  and  of  a  tender  lump  in  the  gi-oin.  The 
conditions  found  on  examination  of  a  chancroidal  ulcer  have  been  described  under 
pathology.  In  the  case  of  mixed  infection,  symptoms  of  secondary  syphilis  de- 
velop after  sufficient  time  has  elapsed. 

Diagnosis. 

The  diagnosis  of  chancroid  is  based  on  the  following  points: 

1.  Development  within  a  few  days  or  a  week  after  suspicious  coitus. 

2.  Location  and  mode  of  development  and  appearance  of  the  lesion. 

3.  Two  or  more  lesions,  indicating  auto-inoculation. 

4.  Absence  of  parchment-like,  or  cartilage-like,  induration  under  the  ulcer. 

5.  Presence  of  a  painful  bubo  tending  to  suppuration. 

6.  In  a  doubtful  case,  a  piece  of  tissue  may  be  excised  from  the  involved  area, 
and  submitted  to  a  bacteriologic  examination,  to  establish  the  presence  or  ab- 
sence of  the  Ducrey  bacillus. 

A  Simple  Ulcer  may  be  due  to  an  abrasion  in  the  first  intercourse  after  mar- 
riage, or  to  infection  of  a  denuded  point  with  ordinary  pus  germs.  A  simple  ulcer 
is  not  so  exclusively  associated  with  coitus,  does  not  give  rise  to  so  much  inflam- 
matory reaction  nor  exhibit  such  an  angry  appearance,  does  not  show  such  a  ten- 
dency to  spread  and  destroy  tissue.  If  kept  clean  for  a  few  days,  it  shows 
healthy  gi-anulations  and  healing  edges,  is  more  liable  to  be  single  (as  auto- 
inoculation  is  not  so  frequent  and  marked)  and  involvement  of  the  lymphatic 
glands  with  suppuration  is  rare. 

In  Herpes,  the  abrasion  is  preceded  by  a  vesicular  eruption  and  there  are 
usually  several  lesions  close  together  or  joined.  The  lesion  is  very  superficial, 
the  red  surafce  being  still  covered  with  a  thin  layer  of  epithelium.  The  margin  is 
small  and  regular  and  there  is  but  little  inflammatory  reaction. 

It  must  not  be  forgotten,  however,  that  an  herpetic  lesion  may  afford  entrance 
to  ordinary  pus  germs  or  to  chancroidal  virus  or  to  syphlitic  infection,  in  which 


424  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

case  characteristic  signs  will  develop  in  due  time.  For  the  distinguishing  char- 
acteristic of  sj^philitic  lesions  and  tubercular  ulcer  and  malignant  ulcer,  see  the 
succeeding  pages. 

Treatment. 

The  treatment  for  chancroid  is  through  cauterization,  to  destroy  the  chancroidal 
virus.  The  earlier  this  is  done  the  fewer  ulcers  there  wdll  be  and  the  less  chance  of 
suppurating  bubo. 

Carbolic  acid  (95%)  is,  I  think,  the  preferable  cauterant  in  the  cases  where  the 
ulcer  is  comparatively  superficial  and  no  general  anesthetic  is  necessary. 

The  ulcer  is  cleansed  and  then  covered  %\dth  a  pledget  of  cotton  soaked  in  20% 
cocaine  solution,  which  is  left  in  place  five  minutes.  Then  remove  the  cotton  and 
cleanse  the  surface  of  the  ulcer  again.  Then  cauterize  every  portion  of  the  ulcer 
with  the  carbolic  acid.  For  applying  this,  a  tooth-pick  with  a  few  shreds  of  cot- 
ton wound  firmly  on  the  end  of  it,  is  very  convenient,  or  a  cotton- wrapped  appli- 
cator may  be  used.  If  any  of  the  carbolic  acid  should  touch  the  skin,  an  immedi- 
ate application  of  alcohol  will  stop  destructive  action 

Rub  the  carbolic  acid  into  every  crevice  and  irregularity  of  the  ulcer,  removing 
any  soft  granulations  and  working  the  cauterant  into  the  depth  of  the  affected 
area.  When  the  surface  has  been  thoroughly  cauterized  then  apply  alcohol  to 
stop  further  action.  Then  cleanse  the  ulcer  and  apply  some  soothing  ointment. 
Vaseline  or  carbolized  vaseline  does  very  well. 

The  patient  should  keep  rather  quiet  (lie  down  most  of  the  time  if  she  can)  for 
a  few  days.  She  should  cleanse  the  parts  frequently  with  the  carbolic  wash  or 
other  antiseptic  wash  and  dry  with  cotton  and  apply  the  vaseline  or  other  oint- 
ment. There  is  some  reaction,  but  that  subsides  after  a  few  days,  and  the  ulcer 
begins  to  show  healthy  granulations  and  rapid  healing.  After  that  the  treatment 
is  the  same  as  for  a  simple  ulcer. 

In  cauterizing  the  ulcer  it  is  important  that  every  particle  of  the  infected  sur- 
face should  be  thoroughly  cauterized,  for  if  active  virus  is  left  at  any  point,  it  will 
reinfect  the  enlarged  ulcer  left  after  the  sloughs  from  cauterization  separate. 

The  advantage  of  carbolic  acid  over  nitric  acid  or  the  thermo-cautery  is  that  it 
is  less  painful.  It  has  an  anesthetic  effect  that  lasts  for  sometime  after  the  cocaine 
anesthesia  has  disappeared.  If  the  ulcer  becomes  very  painful  from  the  reaction 
following  cauterization,  hot  applications  may  give  much  relief.  These  are  made 
by  wringing  a  large  piece  of  absorbent  cotton  out  of  hot  water  or  hot  antiseptic 
solution.  The  moist  cotton,  while  still  steaming,  is  applied  to  the  genitals  and 
covered  with  a  piece  of  oiled-silk.  These  hot  applications  may  be  used  frequently 
if  required  to  relieve  pain.  If  the  sore  is  in  the  vagina,  hot  antiseptic  douches 
should  be  used. 

At  the  office  treatments,  later,  the  ulcer  is  cleansed  with  hydrogen  peroxide, 
dried  with  absorbent  cotton  and  then  dusted  freel}'  with  some  antiseptic  powder. 
Iodoform  is  efficient,  but  its  odor  prevents  its  use.  There  are  a  number  of  good 
powders  \vithout  the  odor.     Among  the  best  are  xeroform  and  aristol. 

The  ulcer  should  be  protected  from  irritation  from  the  clothing  by  a  pad  of  ab- 
sorbent cotton  over  the  genitals.  The  office  treatment  is  repeated  every  second 
or  third  day  until  the  ulcer  is  healed.     For  home  treatment,  the  patient  may  wash 


TREATMENT  OF  CHANCROID  425 

the  genitals  three  or  four  times  daily  with  a  weak  carbolic  solution  or  some  other 
mild  antiseptic. 

If  pain  or  restlessness  is  marked,  a  sedative  may  be  given  as  required  to  produce 
rest.  If  the  patient's  general  health  is  poor,  she  should  of  course  be  given  tonics. 
The  diet  should  be  liberal  and  nourishing.  Alcoholics  are  to  be  avoided  in  most 
cases.     Constipation  must  be  overcome. 

There  is  no  specific  internal  treatment  for  chancroid.  The  following  remedies 
have  been  thought  by  different  observers  to  help  in  controlling  the  ulceration,  and 
it  is  w^ell  to  use  one  of  them  in  severe  cases: 

Calcium  Sulphide,  1-12  to  1-8  gr.  every  four  hours. 

Hydrag-bichloride,  1-50  to  1-30  gr.  three  times  daily. 

Potassio-tartrate  of  Iron,  3  to  5  gr. three  times  daily. 

In  phagedenic  chancroid  cauterization  is  the  most  effective  treatment.  The 
cauterization  must  be  thorough,  extending  into  every  irregularity  of  every  chan- 
croidal lesion  present,  for  if  active  virus  is  left  at  any  point  it  will  reinfect  the 
enlarged  ulcers  left  after  the  sloughs  separate.  If  the  chancroidal  ulceration  is 
extensive  or  if  there  are  sinuses  or  if  there  are  severe  anal  lesions,  it  is  best  to 
give  the  patient  a  general  anesthetic,  that  sinuses  may  be  laid  open  freely  and  all 
lesions  carefully  cauterized.  After  cauterization,  there  is  left  a  simple  ulcer 
which  usually  heals  rapidly  under  the  ordinary  cleansing  and  antiseptic  treat- 
ment previously  given.  If  the  granulations  become  sluggish,  they  may  be  stimu- 
lated by  the  apphcation  of  silver  nitrate  solution  (5%  to  10%)  or  copper  sulphate 
solution  (10%  to  25%).  The  copper  sulphate  is  especially  indicated  where  there 
is  any  hemorrhagic  tendency.  If  the  granulations  are  persistently  unhealthy, 
they  may  be  cleared  away  with  the  sharp  curet  and  the  surface  then  stimulated 
to  healthy  action,  as  above  indicated. 

The  treatment  of  chancroidal  adenitis,  and  of  suppurative  buboes  in  general,  has 
been  the  subject  of  much  thought  and  experimentation. 

Of  first  importance  is  prophylaxis.  The  most  certain  means  of  preventing  a 
bubo  is  to  secure  rapid  healing  of  the  genital  sore.  This  is  one  of  the  strong  points 
in  favor  of  cauterization  of  chancroids,  for  thorough  cauterization,  probably  more 
than  any  other  one  measure,  checks  the  infective  process  and  causes  rapid  healing. 

When  soreness  in  the  groin  with  some  enlargement  of  the  glands  is  noticed,  the 
patient  should  be  put  to  bed  and  kept  there,  and  compresses  wet  in  the  lead  and 
alum  lotion  (see  Formulae)  should  be  applied  to  the  affected  region.  A  piece  of 
absorbent  cotton  is  moistened  with  this  solution  and  then  applied  over  the  affected 
glands  and  held  in  place  by  a  bandage  so  arranged  as  to  make  rather  firm  pressure 
on  the  glands.  A  "  spica"  bandage  is  the  form  usually  used.  The  dressing  should 
be  renewed  two  or  three  times  in  the  twenty-four  hours,  depending  on  the  intensity 
of  the  inflammation.  Spitschka,  who  originated  this  treatment,  regards  it  as  by 
far  the  most  effective  abortive  treatment  in  the  first  stage  of  adenitis,  much  more 
so  than  applications  of  tincture  of  iodine  or  poultices  or  the  ice-bag.  Under  this 
treatment  the  pain  usually  subsides  rapidly,  and  frequently  suppuration  is  pre- 
vented. If  dermatitis  results,  the  solution  may  be  weakened  or  discontinued,  a 
soothing  ointment  being  then  applied. 

Inunction  of  half  a  teaspoonful  of  mercurial  ointment  over  the  tender  glands 


426  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

once  daily  for  a  few  days  is  another  measure  which  seems  to  prevent  suppuration, 
but  mercuriahzation  must  be  guarded  against.  Another  method  much  used,  is 
the  apphcation  of  the  mercury,  belladona  and  iodine  ointment  (see  Formulae) .  The 
ointment  is  rubbed  in  over  the  swollen  glands,  then  cotton  is  applied,  and  over  all 
a  firm  spica  bandage.  The  bandage  should  be  applied  firmly  enough  to  make  con- 
siderable pressure  on  the  glands.  The  dressing  may  be  changed  once  or  twice 
daily. 

If  after  a  few  days  trial  of  one  of  the  above  measures,  the  adenitis  is  still  in- 
creasing, the  time  for  intra-glandular  injection  has  arrived.  Many  solutions  for 
injection  have  been  tried  T\dth  benefit.  Probably  the  best  injection-solution  is  the 
1%  solution  of  benzoate  of  mercury,  recommended  by  Welander.  With  an  ordi- 
nary hypodermic  syringe,  five  to  ten  drops  of  this  solution  is  injected  into  each  of 
the  enlarged  glands,  the  skin  having,  of  course,  been  thoroughly  disinfected.  The 
needle  may  be  entered  at  several  points,  if  necessary  to  reach  the  various  glands. 
The  total  amount  of  solution  injected  should  not  exceed  twenty  or  thirty  drops. 

The  injection  causes  considerable  reaction,  as  evidenced  by  pain  and  swelling 
and  some  fever.  After  two  or  three  daj^s,  the  irritation  subsides  and  usually  reso- 
lution takes  place,  if  the  buboes  were  not  fluctuating  at  the  time  of  injection.  If 
one  injection  is  not  sufficient,  another  may  be  made  after  several  days,  even  though 
fluctuation  is  present. 

If  the  evidence  of  fluid  persists  several  days  after  all  irritation  from  the  injection 
has  subsided,  the  abscess  should  be  opened  by  incision  and  the  incision  kept  open 
by  a  strip  of  antiseptic  gauze,  and  the  cavity  treated  in  the  ordinarj^  way  with  per- 
oxide and  bichloride  solution. 

Some  cases  presenting  fluctuation  have  been  cured  by  injection.  Even  when 
incision  later  is  necessary  the  injection  seems  to  be  beneficial  in  three  ways: 

a.  The  glands  opened  after  injection  rarely  show  chancroidal  ulceration,  but 
heal  as  simple  abscesses. 

b.  Complete  liquifaction  of  all  involved  tissues  is  more  frequent,  so  that  deep 
curetting  or  extirpation  of  partially  broken-do-^m  glands  is  rarely  necessary. 

c.  Other  glands  are  seldom  involved  after  the  injection  of  those  first  affeeted, 
consequently  man}^  glands  are  saved  and  an  extensive  scar  avoided. 

The  most  certain  and  rapid  method  of  curing  a  chancroidal  bubo  in  an  earl}- 
stage  is  to  completely  excise  the  affected  glands  and  close  the  wound  immedi- 
ately by  sutures.  However,  only  a  small  proportion  of  patients  will  submit  to 
this  radical  treatment,  particularly  in  view  of  the  fact  that  many  buboes  recover 
without  suppuration.  Then  there  is  the  danger  of  the  general  anesthetic,  slight 
to  be  sure,  but  ever  present. 

After  the  bubo  has  resisted  abortive  measures  several  days,  suppuration  is  very 
probable  and  complete  extirpation  ma}'  then  l)e  urged  with  more  force.  Most  pa- 
tients, however,  prefer  the  less  radical  injection  method  and  some  object  even  to 
that,  insisting  on  simple  external  applications  to  relieve  the  pain  and  incision  later 
when  absolutely  necessary. 

A  chancroidal  sinus,  persisting  from  a  bubo,  may  be  injected  with  iodoform  in 
glycerine  (10%)  once  daily,  after  washing  out  with  peroxide.  If  this  does  not  cause 
the  sinus  to  heal  it  mav  be  curetted  with  a  small  curet  under  cocaine  anesthesia. 


SYPHILIS  427 

If  it  still  persists  there  are  probably  broken  down  glands  that  must  be  completely 
extirpated  under  a  general  anesthetic,  before  healing  can  take  place. 

SYPHILIS 

OF  Vulva  and  ^'AGINA. 

Syphilis  is  a  general  infectious  disease,  characterized  by  an  initial  sore  (the  point 
of  entrance  of  the  infecting  germ)  and  by  general  secondary  manifestations  after 
several  weeks  and  by  tertiary  lesions,  localized  in  various  parts  of  the  body,  after 
several  years. 

The  infectious  agent  is  the  spirochaete  pallida,  a  very  small  microbe  which  is 
found  in  all  lesions  (primary,  secondary  and  tertiary).  The  demonstration  of 
this  germ,  makes  possible  a  positive  diagnosis  of  syphilis  at  once,  even  in  the 
primary  stage  and  long  before  the  clinical  evidences  appear.  The  positive  iden- 
tification of  this  infectious  germ  requires  considerable  bacteriologic  experience, 
hence  the  specimens  should  be  sent  to  a  pathologist. 

The  following  directions  for  preparing  specimens,  are  those  given  by  Dr.  Carl 
Fisch,  of  this  city,  who  has  done  much  work  with  the  spirochaete  paHida. 

In  the  case  of  a  suspected  primary  lesion  (chancre),  wipe  the  surface  of  the 
ulcer  clean,  with  cotton  or  gauze,  and  then  scarify  the  surface  with  a  needle. 
From  the  "irritation  serum"  which  results,  make  a  spread=preparation  on  a  slide 
or  cover-glass,  just  as  in  making  a  preparation  of  blood.  Half  a  dozen  speci- 
mens are  made  and  dried  and  then  packed  for  transmission. 

In  SECONDARY  LESIONS  (mucous  patchcs,  moist  papules ,  dry  papules) ,  a  spread- 
preparation  of  the  "irritation  serum",  made  as  above  directed,  will  usually  suf- 
fice for  a  diagnosis.  A  negative  finding,  however,  does  not  certainly  exclude 
syphilis.  Consequently,  to  make  the  diagnosis  certain ,  a  tissue=specimen  should 
be  examined.  This  is  easily  secured  by  clipping  off  a  small  papule.  Preserve 
all  tissue-specimens  to  be  examined  for  the  spirochaete  pallida,  in  10%  formol 
solution.     Specimens  preserved  in  alcohol  do  not  do  so  well. 

In  TERTIARY  LESIONS  Only  tissue=specimens  can  be  used  for  diagnosis,  and  they 
must  be  taken  from  the  capsule,  or  tissue  about  the  gumma.  The  gummatous 
material,  or  necrotic  material  in  the  center  of  a  "gumma",  is  not  suitable  for 
such  diagnostic  examination. 

Syphilis  may  be  hereditary  or  r.cquired.  In  the  hereditary  form  the  lesions  of 
the  genitals  either  constitute  only  a  small  part  of  the  general  syphilitic  picture,  as 
in  the  severe  cases  leading  to  death  of  the  infant,  or  appear  as  ordinary  tertiary 
lesions  later  in  life.  Consequently  hereditary  syphilis  requires  no  special  consider- 
ation in  this  connection.  Acquired  siphilis  is  due  to  inoculation  of  a  crack,  scratch 
or  abrasion  with  secretion  from  a  syphilitic  sore  or  with  syphilitic  blood. 

In  the  case  of  a  primary  sore  of  the  vulva  or  vagina,  there  has,  of  course,  been 
contact  of  the  genitals  with  the  syphilitic  virus,  either  by  sexual  intercourse, 
which  is  the  more  common  way,  or  by  contact  with  contaminated  clothing  or 
fingers  or  household  utensils  or  bath-room  articles  (particularly  the  water-closet 
seat  in  pul^lic  places).     In  the  case  of  tertiary  or  secondary  lesions  of  the  genitals. 


428  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

the  primary  lesion  may  have  been  on  the  genitals  or  on  any  other  part  of  the 
body. 

Pathology,  Symptoms,  Diagnosis. 

Syphilis  of  the  vulva  or  vagina  may  appear  in  the  form  of  primary  or  secondary' 
or  tertiary  lesions. 

Primary  lesions.  For  a  period  of  two  to  three  weeks  after  infection  with  syph- 
ilitic virus,  there  is  nothing  to  indicate  that  such  infection  has  taken  place.  The 
small  abrasion,  through  which  the  infection  took  place,  heals  in  a  few  days  as 
though  nothing  had  happened  and  there  is  apparently  no  morbid  process  going 
on  there.  This  is  known  as  the  "first  incubation  period."  In  exceptional  cases 
it  may  be  less  than  two  weeks  or  more  than  three  weeks,  sometimes  extending  to 
six  or  even  eight  weeks. 

At  the  end  of  the  incubation  period  a  papule  appears  at  the  point  of  infection. 
If  the  ^irus  entered  at  two  or  three  points,  there  may  be  a  like  number  of  lesions, 
but  this  is  exceptional.  The  small  red  papule  is  the  usual  form  which  the  initial 
lesion  takes.  The  papule  may  be  decidedly  elevated  and  pointed,  or  it  may  be 
fiat  and  scarcely  raised  above  the  surface,  but  in  either  case  some  induration, 
slight  at  first,  may  be  felt. 

If  this  papule  is  situated  on  the  external  surface  and  is  kept  dry,it  remains  simply 
as  a  dr}'  papule  -^ith  some  scaling  but  no  ulceration.  This  form  of  primary  lesion 
is  kno-^m  as  the  dr}'  scaling  papule.  It  enlarges  peripherally  and  may  var^-  in  size 
from  a  pea  to  a  dime.  Exceptionally,  the  fiat  papule  may  grow  to  the  size  of  a 
silver  quarter. 

The  induration  also  increases,  and  at  the  end  of  a  week  or  ten  days  is  character- 
istic. The  best  way  to  feel  this  induration  is  to  grasp  the  lesion  between  the  thumb 
and  finger  and  gently  squeeze  it  or,  more  accurately,  squeeze  the  tissues  beneath 
it.  The  induration  assumes  two  forms.  It  may  be  present  as  a  thin  dense  layer 
under  the  papule  or  ulcer.  When  grasped  as  just  indicated,  such  form  of  indura- 
tion gives  the  sensation  of  a  small  piece  of  thick  T\Titing-paper  or  stiff  blotting- 
paper  lying  horizontally  under  the  lesion.  The  margins  are  quite  distinct  and, 
when  pressed,  the  plate  of  induration  can  be  felt  to  bend  much  as  a  piece  of  blot- 
ting paper  would.  This  is  called  "parchment  induration."  On  the  other  hand, 
the  induration  may  be  present  as  a  thick  rounded  mass,  occupying  the  base  of  the 
papule  or  ulcer  and  extending  a  considerable  distance  below  it.  This  area  of  in- 
duration is  in  the  form  of  a  nodule  which  is  dense  and  firm  and  presents  distinct 
outlines.  When  examined  by  grasping,  as  before  described,  it  gives  the  impres- 
sion of  a  piece  of  cartilage  beneath  the  sore  and  is  kno\^TL  as  "  cartilaginous  indura- 
tion," called  also  "nodular  induration." 

The  induration  of  a-  syphilitic  chancre  disappears  very  slowly.  When  well 
marked  it  persists  through  the  second  incubation  period,  i.  e.,  until  the  develop- 
ment of  secondary  symptoms,  and  then  gradually  undergoes  involution.  As  a 
rule,  the  primar}'  lesion  with  its  accompanying  induration,  disappears  completely 
within  six  to  eight  weeks  after  the  beginning  of  the  secondaries.  Frequently  some 
induration  or  a  pigmented  spot  marks  the  cite  for  several  months  longer,  and  oc- 
casionally the  indurated  tissue  becomes  somewhat  organized  and  persists  indefi- 
nitely as  a  small  hard  nodule  of  scar  tissue. 


VARIOUS  FORMS  OF  PRIMARY  SYPHILITIC  LESION  429 

Another  form  of  primary  lesion  is  the  superficial  erosion.  This  is  noticed  as  a 
small  round  or  oval  red  spot  which  may  or  may  not  be  slightly  raised.  The  center  is 
often  slightly  depressed.  The  top  layers  of  epithelium  over  this  spot  have  been 
thrown  off,  forming  a  superficial  abrasion,  or  raw  place,  called  an  erosion.  A  thin 
gray  film  usually  occupies  the  center  of  the  lesion  and  in  many  cases  covers  all  of 
it.     The  characteristic  induration  is  present. 

A  third  form  of  initial  lesion  is  the  indurated  ulcer.  If  either  the  dry  papule  or 
the  superficial  erosion  lose  all  their  epithelium,  so  that  granulation  tissue  forms, 
there  is  an  ulcer  with  an  indurated  base.  This  transformation  is  especially  liable 
to  take  place  when  the  lesion  is  kept  moist,  hence  it  is  most  frequently  met  with  in 
the  vagina  or  on  the  inner  surfaces  of  the  labia.  It  may,  however,  occur  in  any  situ- 
ation, and  in  many  cases  the  ulcer  is  apparently  present  almost  from  the  begin- 
ning. This  indurated  ulcer  was  the  first  form  of  primary  lesion  recognized  as  in- 
dicating infection  from  syphilis,  and  to  it  were  given  the  names  "hard  chancre" 
and  "hard  sore"  and  "Hunterian  chancre." 

Any  of  the  three  forms  of  primary  lesion  may  be  small  or  large.  Unless  accom- 
panied with  pus  infection,  they  give  rise  to  very  little  pain  or  disturbance,  and  if 
small  may  be  overlooked  entirely  by  the  patient.  Many  women  presenting  un- 
mistakable evidences  of  syphilis  can  give  no  history  of  a  primary  sore  because  it 
escaped  their  notice.  This  is  especially  liable  to  occur  if  the  lesion  is  situated  in 
the  vagina.  Furthermore,  a  small  primary  lesion  in  the  vagina  may,  after  a  short 
time,  disappear  so  completely  that  even  the  physician  can  find  no  trace  of  it. 

There  is  a  fourth  form  of  primary  lesion,  and  that  is  the  mixed  sore.  By  a 
"mixed  sore"  is  meant  a  sore  with  a  double  infection — both  chancroidal  and 
syphilitic,  the  former  disease  being  manifest  first,  and  the  latter,  two  to  four  weeks 
later.  At  first  the  sore  is  apparently  an  ordinary  chancroid,  but  after  two  or 
three  weeks  the  sore  loses  its  chancroidal  characteristics,  induration  appears  under 
it  and  an  ordinary  hard  chancre  develops,  to  be  followed  by  other  eviderres  of 
sjqjhilis.  In  other  cases,  the  chancroidal  ulceration  heals  during  the  incubation 
of  the  syphilitic  germ,  but  at  the  end  of  that  period  the  scar  becomes  indurated, 
perhaps  ulcerated,  and  a  primary  syphilitic  lesion  appears. 

A  primary  syphilitic  ulcer  does  not  present  the  angry  appearance  and  destructive 
characteristics  of  the  chancroidal  sore.  It  is  apparently  a  much  less  virulent  affair. 
The  edges  are  not  undermined  but  slope  inward,  there  is  not  such  a  marked  zone 
of  inflammatory  reaction  and  the  ulcer  does  not  spread  so  rapidly  nor  so  persist- 
ently. It  is  more  indolent  and  frequently  is  nearly  painless.  In  fact,  the  absence 
of  pain,  such  as  would  ordinarily  be  expected  from  the  size  and  location  of  the 
sore,  is  one  of  the  striking  characteristics  of  syphilis.  But  any  syphilitic  lesion 
may  become  infected  with  ordinary  pus  germs,  in  which  case  it  usually  becomes 
painful.  The  primary  sore  may  heal  within  a  week  or  two  after  its  appearance, 
or  it  may  persist  all  through  the  second  period  oi  incubation. 

The  primary  syphilitic  lesion  of  the  external  genitals  is  accompanied  by  enlarge^ 
ment  and  induration  of  the  inguinal  glands  on  the  same  side  as  the  lesion.  This 
enlargement  may  be  marked  or  it  may  be  slight,  but  it  is  always  present.  It  be- 
gins in  a  week  after  the  appearance  of  the  primary  lesion.  It  is  due  to  an 
indolent  inflammation  or  induration  of  the  glands.     Several  glands  are  affecteci 


430  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

and  they  may  be  felt  as  distinct  painless  nodules,  entirely  separate  and  freely 
movable.  Unless  there  is  a  mixed  infection,  with  chancroidal  virus  or  with  ordi- 
nary pus  germs,  the  glands  do  not  present  any  evidence  of  acute  inflammation  and 
there  is  no  suppuration. 

Secondary  Lesions.  On  the  vulva,  secondary  syphilis  usually  manifests  itself 
by  the  development  of  moist  papules,  called  also  "condylomata  lata"  (Figs. 
261,  262).  These  may  appear  any  time  during  the  first  twelve  months  of  the  sec- 
ondary period.  The  syphilitic  condyloma  consists  of  a  slightly  elevated,  flattened 
area  from  which  part  of  the  epithelial  covering  has  been  thrown  off.  It  may  be 
any  size  from  the  head  of  a  pin  to  as  large  as  the  thumb-nail.  There  are  usually 
several  lesions  and  in  some  cases  dozens  of  them.  The  individual  lesions  have  a  fairly 
regular  circular  or  elliptical  outline.  Several  of  them  may  coalesce,  forming  large  ir- 
regular infiltrated  patches  (Fig.  261).  In  some  cases  there  is  a  slight  secretion,  and 
all  of  them  are  kept  moist  a  portion  of  the  time  l^y  the  secretion  from  the  vagina. 
They  are  not  painful  and  cause  very  little  disturbance,  except  when  irritated. 
When  the  vaginal  discharge  is  very  irritating,  some  of  the  lesions  may  becomes  in 
flamed,  in  which  case  they  are  reddened  and  angry-looking  and  painful.  When 
inflamed,  the  thin  epithelium  may  be  lost,  giving  rise  to  an  ulcer  which  may  in- 
volve a  part  or  all  of  the  lesions.  Sometimes  abrasions  on  the  lesions  are  caused 
by  scratching. 

The  favorite  locations  for  the  moist  papules  or  flat  condylomata,  are  the  labia 
minora  and  the  inner  surfaces  of  the  labia  majora.  In  some  cases,  however,  they 
cover  all  the  external  genitals  and  extend  even  on  the  adjacent  surfaces  of  the 
thighs  (Fig.  262). 

Associated  with  them  are  other  evidences  of  secondary  syphilis,  such  as  a  gen- 
eral eruption,  enlargement  of  the  inguinal  and  epitrochlear  and  post-cervical 
glands,  persistent  sore  throat,  sores  in  the  mouth  and  loosening  of  the  hair. 

Tertiary  Lesions.  Tertiary  syphilis  of  the  vulva  and  vagina  usually  presents 
itself  in  the  form  of  persistent  and  destructive  ulceration.  When  occuiring  in  the 
vicinity  of  the  vestibule,  it  not  infrequently  leads  to  destruction  of  the  urethra. 
Its  victims  are  usually  in  a  state  of  poor  health  and  lowered  vitality.  They  have 
little  tissue  resistance,  hence  the  destructive  action  of  the  ulcer.  Coincident  ulcera- 
tion of  the  rectum,  with  stricture  formation,  is  frequent.  When  syphilitic  ulcera- 
tion affects  the  upper  part  of  the  vagina  or  the  cervix  uteri  it  may  be  mistaken  for 
cancer. 

A  tertiary  syphilitic  ulcer  is  usually  indolent,  comparatively  painless  and  persist- 
ent in  spite  of  local  treatment.  There  are  usually  other  evidences  of  tertiary 
syphilis  or  a  history  of  previous  secondary  or  tertiary  symptoms.  The  ulceration 
heals  under  anti-syphilitic  treatment,  provided  the  patient's  vitality  is  not  so 
lowered  that  the  normal  tissue  resistance  is  destroyed. 

The  diagnosis  of  tertiary  syphilitic  ulcer  is  made  principally  by  the  presence  of 
other  evidences  of  syphilis,  l)y  the  exclusion  of  other  forms  of  chronic  ulceration 
(chancroid,  tuberculosis,  cancer)  and  by  the  effect  of  treatment,  local  and  consti- 
tutional. In  the  case  of  persistent  ulcer,  of  doubtful  character,  a  piece. of  the 
margin  of  the  ulcer  should  be  excised  for  microscopic  examination. 


TUBERCULOSIS  OF  VULVA  4;-{l 

Treatment. 

A  patient  should  not  be  given  coiLstitutional  treatment  for  syphilis  until  the 
diagnosis  is  positive.  As  a  rule  a  positive  diagnosis  before  the  appearance  of  the 
"secondaries"  is  not  possible  by  the  ordinary  clinical  evidences.  By  Imcterio- 
logic  examination,  however,  a  positive  diagnosis  may  be  made  at  once,  even  in 
the  very  earliest  stage  of  the  primary  lesion. 

When  the  diagnosis  is  thus  made  early,  it  is  recommended  by  some  author- 
ities that  the  primary  lesion  be  at  once  completely  exci.sed — not  with  the  idea 
of  preventing  general  syphilis,  but  to  modify  it  and  lessen  the  effect  of  the 
succeeding  stages.  This  excision  treatment  of  the  primary  lesion  is  still 
experimental. 

Otherwise  the  only  treatment  that  the  primary  lesion  requires  is  local  cleansing 
and  antiseptic  measures,  such  as  are  recommended  under  Simple  Ulcer.  The  sec- 
ondary and  tertiary  lesions  require  regular  constitutional  treatment  for  syphilis, 
i.  e.,  mercury  in  the  secondary  stage,  iodides  and  tonics  in  the  tertiary  stage  and 
a  combination  of  the  two  in  the  intermediate  stage  (late  secondary  and  early  ter- 
tiary). For  the  details  of  the  internal  treatment  of  syphilis  the  reader  is  referred 
to  works  treating  of  that  subject. 

The  local  treatment  for  the  secondary  and  tertiary  lesions  of  the  vulva  and  va- 
gina, is  simply  cleansing  and  antiseptic  and  astringent,  i.  e.,  the  same  as  for  Simple 
Ulcers.  Arg3Tol  (25%),  protargol  (10%),  silver  nitrate  (2%  to  10%)  are  excellent 
applications  for  mucous  patches.  Bichloride  solution  (1-2000)  is  a  good  wash  for 
the  same.  Calomel  as  a  dusting  powder  is  also  useful  in  relieving  the  irritation. 
These  applications  are  likewise  beneficial  in  tertiary  ulcers.  For  cleansing  all  the 
irregularities  of  a  deep  ulcer,  hydrogen  peroxide  is  effective.  When  there  is  a 
tendency  to  bleed,  copper  sulphate  solution  (10%)  may  be  used. 

Ravogli  highly  recommends  emplastrum  hydrargyri  as  an  application  in  tertiary 
S3''philitic  ulcerations.  Wash  the  ulcer  with  bichloride  solution  (1-2000)  and  then 
apply  the  emplastrum  hydrargyri.  This  causes  temporary  increase  in  the  dis- 
charge due  to  the  breaking  down  and  discharge  of  the  unhealthy  gi-anulations 
and  detritus  at  the  bottom  of  the  ulcer.  After  a  few  applications  healthy  granu- 
lations appear  and  healing  begins.  After  that  the  ulcer  is  given  ordinary  anti- 
septic treatment,  i.  e.,  it  is  washed  with  bichloride  solution  or  hydrogen  peroxide, 
or  both,  and  then  dusted  with  an  antiseptic  powder. 

TUBERCULOSIS  OF  VULVA. 

Tuberculosis  of  the  vulva  is  the  term  applied  to  those  lesions  of  the  external 
genitals  produced  by  tubercle  bacilli.  Tuberculosis  of  this  region  and  other  forms 
of  persistent  vulvar  ulceration  were  formerly  described  together  under  the  terms 
"lupus  vulvae,"  "lupus  hypertropicus,"  "lupus  perforans,"  "ulcus  rodens,"  "de- 
structive ulcer  of  vulva"  and  "perforating  ulcer  of  vulva."  As  the  pathology  of 
the  various  forms  of  ulceration  was  gradually  worked  out,  it  was  found  that  in  many 
of  the  cases  of  destructive  ulceration,  tubercle  bacilli  were  present.  The  tuber- 
cular lesion^,  were  then  formed  into  a  class  by  themselves  and  this  class  includes  a 


432  DISEASES  OF  EXTERNAL  CENITALS  AND  VAGINA 

large  number  of  the  cases  of  persistent  ulceration  formerly  described  under  the 
titles  above  mentioned. 

Tuberculosis  of  the  vulva  is  due  to  local  infection  -^ith  the  tubercle  bacillus. 
The  infection  may  take  place  through  an  abrasion,  in  which  case  the  infecting 
germ  may  be  brought  to  the  abrasion  by  a  tubercular  discharge  from  the  uterus 
or  vagina,  or  possibly  by  coitus  with  a  husband  having  a  tubercular  lesion  of  the 
genito-urinary  tract  or  by  fingers  or  clothing  infected  with  tubercular  discharge 
either  from  the  patient  or  from  some  other  person. 

On  the  other  hand,  tissues  may,  in  rare  cases,  be  infected  without  any  break  in 
the  epithelial  covering.  In  such  a  case  the  tubercle  bacilli  may  come  by  way  of 
the  blood  or  lymph. 

Tuberculosis  of  the  vulva  begins  as  a  small  nodule,  usually  situated  near  the 
meatus  or  the  clitoris  or  at  the  posterior  commissure.  It  may  be  of  a  dusky  red 
or  bluish  color.  Microscopic  examination  of  such  a  nodule  shows  the  usual  round- 
cell  infiltration,  the  necrotic  areas,  the  giant  cells  and  the  tubercle  baciUi,  found 
in  tubercular  lesions  elsewhere.  There  may  be  only  a  single  nodule  or  there 
may  be  many.  After  a  time  the  nodules  break  down  and  form  small  ulcers.  The 
ulcers  have  hard  margins  and  an  irregular  base  and  are  very  hable  to  have  an  area 
of  irregular  infiltration  about  them.  The  ulcers  discharge  some,  and  this  dis- 
charge may  or  may  not  show  tubercle  bacilli.  As  the  ulcers  enlarge  they  coalesce, 
forming  extensive  areas  of  ulceration  of  very  irregular  outline  (Fig.  219).  As  the 
ulcer  extends  at  one  part  it  may  heal  at  another,  giving  rise  to  much  scar  tissue. 
By  gradual  contraction  the  scar  tissue  interferes  with  the  local  circulation  of  the 
blood  and  lymph  and  may  lead  to  marked  stasis  hypertrophy  and  induration  of 
the  labia  and  clitoris. 

Tubercular  ulcers  are  chronic  and  persistent  and  may  extend  deeper  and  deeper 
until  fistulous  openings  are  formed  into  the  rectum  or  bladder  or  urethra,  hence 
the  name  perforating  ulcer.  Even  when  adjacent  cavities  are  not  opened,  the 
ulcers,  in  conjunction  with  the  contracting  scar  tissue,  may  form  sinuses  and  dis- 
charging surfaces  extending  deeply  in  various  directions,  and  sometimes  causing- 
perforations  through  the  labia. 

A  positive  diagnosis  requires  a  microscopic  examination.  In  a  doubtful  case 
the  crucial  test  of  the  character  of  the  ulceration  consists  in  finding  tubercle  bacilli 
in  the  secretion  or  in  demonstrating  the  characteristic  pathological  changes  in  a 
specimen  of  tissue  removed  from  the  margin  of  the  ulcer. 

Treatment.  If  there  are  no  marked  tubercular  lesions  elsewhere,  the  whole  in- 
filtrated area  should  be  excised  and  the  wound  closed  by  sutures.  If  the  infiltra- 
tion can  not  be  excised,  the  ulcer  should  be  thoroughly  curetted  and  then  deeply 
cauterized  with  carbolic  acid  or  the  thermo-cautery.  If  the  patient  does  not  wish 
these  severe  measures,  the  surfaces  may  be  touched  frequently  with  tincture  of 
iodine  or  with  lactic  acid  and  then  powdered  with  iodoform.  In  some  cases  the 
use  of  these  substances  causes  healing.  At  the  same  time  the  patient  should  re- 
ceive constitutional  treatment  for  tuberculosis.  If  any  new  areas  of  the  tuber- 
cular process  crop  out  they  should  be  given  the  treatment  found  effective  Avith 
the  first  lesion.  When  the  disease  is  still  in  the  stage  represented  by  small  nodules, 
the  following  treatment  is  recommended  by  Unna.     A  number  of  the  nodules  are 


TUBERCULOSIS  OF  VAGINA  43^} 

punctured  with  an  acne-lance.  Tlien  a  small  shred  of  absorbent  cotton  is  moist- 
ened in  a  mixture  of  mercury  (one  part),  carbolic  acid  (four  parts)  and  alcohol 
(twenty  parts),  and  pushed  into  the  lance  opening  with  a  sharp-pointed  instru- 
ment and  turned  about  and  left  there  ten  or  fifteen  minutes.  In  three  to  five  days 
the  irritation  has  subsided  and  other  nodules  may  be  treated  in  the  same  way, 
and  thus  the  process  is  continued  until  all  traces  of  the  tubercular  infiltration  has 
disappeared. 

For  tuberculosis  of  the  vulva  and  for  rodent  ulcer,  there  is  a  treatment  which 
promises  to  be  superior  to  any  other  yet  devised,  not  excepting  the  knife. 
I  refer  to  treatment  by  the  X-Ray  and  by  the  Finsen  light.  In  superficial  tuber- 
culosis, a  cure  is  almost  certain  and" with  comparatively  little  disturbance  of  health}/ 
tissue.  In  ]3oth  of  these  affections  this  treatment  is  as  a  rule  preferable  to  the 
knife.  The  treatment  is  long  but  it  gives  better  results,  i.  e.,  there  is  as  large  a 
percentage  of  cures,  with  less  disfigurement  and  with  practically  no  pain. 

TUBERCULOSIS  OF  VAGINA. 

Tuberculosis  of  the  vagina  is  usually  secondary  to  tuberculosis  of  the  uterus  and 
tubes,  the  vaginal  surface  being  infected  from  the  tubercular  discharge  from 
above.  Some  cases  occur,  however,  in  which  there  is  no  tubercular  trouble  higher 
in  the  genital  tract.  In  such  a  case  the  vaginal  tuberculosis  may  be  due  to  sexual 
intercourse  with  a  husband  having  tubercular  lesion  of  the  genital  tract,  or  to  the 
use  of  an  infected  douche-nozzle  or  to  the  extension  inward  from  tuberculosis  of 
the  vulva. 

The  most  common  site  for  vaginal  tuberculosis  is  the  posterior  vaginal  fornix, 
which  region  comes  most  in  contact  with  the  uterine  discharges.  It  is  supposed 
that  the  resistance  of  the  vaginal  epithelium  must  be  lowered  by  an  irritating  dis- 
charge or  otherwise,  before  invasion  by  the  tubercle  bacillus  can  take  place.  The 
first  manifestation  of  tuberculosis  of  the  vaginal  wall  is  the  development  of  a  num- 
ber of  miliary  tubercles.  These  may  be  confined  to  a  small  area,  for  example,  to 
the  posterior  fornix,  or  may  appear  over  a  large  part  of  the  surface  at  once. 

Each  miliary  tubercle  is  a  small,  raised,  grayish  or  yellowish  dot,  the  size  of  a 
millet  seed  or  smaller.  As  the  lesions  develop  they  break  down  and  form  small 
ulcers,  which  may  coalesce  and  form  ulcers  of  various  sizes.  The  tubercular  ulcer 
has  a  punched  out  appearance,  the  edges  being  perpendicular,  and  the  base  is 
yellowish  gi-ay  and  may  show  many  miliary  tubercles.  The  miliary  tubercles 
frequently  occur  in  large  numbers  in  the  hyperemic  zone  about  the  ulcer. 

Symptoms  and  Diagnosis.  The  stage  of  ulceration  is  usually  the  time  at  which 
the  patient  consults  the  physician,  complaining  of  discharge  and  discomfort. 
Examination  reveals  the  suspicious  ulcer  or  ulcers  and  further  investigation  wil' 
usually  show  tubercular  disease  of  the  uterus  or  tubes. 

The  discharge  from  a  tubercular  ulcer  contains  tubercle  bacilli,  but  sometimes 
in  such  small  numbers  that  they  are  not  found  when  the  discharge  is  stained  and 
examined.  In  a  doubtful  case,  some  tissue  from  the  margin  of  the  suspected 
ulcer  may  be  sent  to  a  pathologist  for  examination.  In  such  a  specimen,  in  ad- 
dition to  the  tubercle  bacilli,  there  are  found  the  characteristic  giant  cells  and 
necrotic  areas.     Another  way  of  testing  for  tuberculosis  in  the  laboratory,  is  by 


434  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

injecting  some  of  the  secretion  into  the  peritoneal  cavity  of  a  guinea  pig,  where  it 
causes  tubercular  peritonitis  with  characteristic  lesions. 

Treatment.  The  treatment  is  the  same  as  that  described  under  tuberculosis  of 
vulva. 

MALIGNANT  DISEASE  OF  THE  VULVA. 

Carcinoma  and  sarcoma  may  affect  the  external  genitals,  In  this  situation  they 
are  distinguished  by  the  same  signs  that  characterize  them  elsewhere,  namely, 
progressive  induration,  ulceration  and  involvement  of  the  neighboring  lymph 
glands.     Malignant  disease  of  the  external  genitals  is  rather  rare. 

Epithelioma  is  the  most  frequent  form.  This  begins  usually  on  the  lower  por- 
tion of  the  labium  majus  as  a  small  hard  nodule  with  a  bluish  tinge  especially  about 
the  edge.  The  nodule  grows  slowly  and  at  first  may  produce  no  symptoms.  In 
some  cases,  however,  even  from  the  first  there  is  severe  pruritis.  After  a  time, 
part  of  the  nodule  breaks  down,  forming  a  small  ulcer  which  is  surrounded  by  an 
area  of  induration.  There  is  a  watery  discharge  sometimes  mixed  with  blood. 
When  occurring  about  the  meatus  it  sometimes  causes  the  urethra  to  appear  as  a 
firm  indurated  cylinder.  The  progress  of  the  disease  is  now  more  rapid,  the  ex- 
tension-being usually  in  the  long  axis  of  the  labium.  Later,  the  adjacent  surfaces 
and  structures  become  involved.  A  fungus  or  protruding  gi'owth  may  appear. 
Figs.  220,  221,  222,  270,  271  and  272,  show  various  cases  of  epithelioma  of  vulva. 

The  inguinal  glands  become  enlarged  early,  at  first  simply  from  the  lymphatic  en- 
largement that  always  takes  place  when  there  is  inflammation  or  persistent 
irritation  of  the  genital  region.  Later  the  glands  become  infiltrated  with  cancer 
cells  and  often  gi-eatly  enlarged.  In  the  latter  stage  the  carcinomatous  glands 
break  down  and  ulcerate  externally. 

Experience  has  shown  that,  unless  recognized  and  extirpated  very  early,  the  dis- 
ease is  usually  incurable.  Its  duration  from  the  beginning  is  usually  about  two 
years. 

The  patient  may  suffer  from  burning  and  superficial  pain  in  the  early  stages  and 
later  there  may  be  severe  pain  from  involvement  of  the  deeper  structures.  Car- 
cinoma of  the  clitoris  (Fig.  222)  has  been  observed  a  number  of  times.  Frequently 
it  is  melanotic.  A  more  rare  location  for  cancer  is  the  vulvo- vaginal  gland,  the 
particular  form  of  growth  originating  here  being  the  adeno-carcinoma  (Fig.  273). 
In  all  of  these  forms  of  growth,  extirpation  in  a  very  early  stage  gives  the  only 
probability  of  cure.  Consequently,  in  the  case  of  a  suspicious  ulcer  or  nodule  in 
which  the  diagnosis  remains  doubtful  after  careful  treatment  for  a  short  time,  a 
\jiece  of  the  margin  of  the  area  should  be  excised  for  microscopic  examination. 

Treatment.  Ea-rly  and  wide  excising  is  the  treatment  to  employ  when  the  dis- 
ease is  operable.  No  time  should  be  wasted  with  X-ray  or  other  uncertain  methods. 
After  extirpation,  X-ray  treatment  may  be  used  to  prevent  recurrence. 

If  the  malignant  infiltration  has  gone  too  far  for  complete  removal,  palliative 
measures  must  be  employed.  These  consist  of  general  sedatives  and  local  appli- 
cations to  relieve  pain,  curetment  and  cauterization  of  the  ulcer.  X-ray  treatment 
and  the  employment  of  the  various  measures  mentioned  under  simple  ulcer.  In 
advanced  cases  there  is  so  much  destruction  of  tissue  by  ulceration  that  it  is  difficult 


MALIGNANT  DISEASE  OF  VAGINA  435 

to  keep  the  ulcerating  surface  clean  and  free  from  odor.  Iodoform  and  charcoal, 
half  and  half,  sprinkled  freely  over  the  surface  and  covered  with  gauze,  aids  in  this. 
The  salicylic  acid  and  iodoform  powder  (see  Formulae)  has  much  the  same  effect. 
In  the  inoperal:)le  cases,  opium  will  be  required  sooner  or  later  to  diminish  suffer- 
ing, and,  when  needed,  it  should  l^e  given  freely  and  gradually  increased  as  re- 
quired to  give  relief.  In  the  inoperable  cases,  particularly  the  cases  of  sarcoma, 
the  mixed  toxins  of  the  streptococcus  and  bacillus  prodigiosis  (Coley's  toxins) 
may  be  found  beneficial.  If  these  fail,  the  growth  may  be  somewhat  retarded  by 
repeated  injection  of  a  few  drops  of  alcohol  in  various  parts  of  the  growth.  These 
injections  may  be  repeated  every  two  or  three  days  or  at  longer  intervals,  according 
to  the  disturbance  they  cause. 

MALIGNANT  DISEASE  OF  THE  VAGINA. 

Carcinoma  of  the  vagina  is  usually  secondary  to  carcinoma  of  the  uterus  or  rec- 
tum or  bladder  or  external  genitals,  and  the  treatment  depends  on  the  situation  and 
extent  of  the  principal  lesion.  Primary  carcinoma  of  the  vagina  is  rare.  It  is 
of  the  squamous-cell  variety  (epithelioma)  and,  according  to  Pozzi,  it  occurs  in 
two  forms. 

1.  As  a  papillary  gi'owth.  This  form  usually  attacks  the  posterior  wall  of  the 
vagina,  making  its  appearance  as  a  broad-based  excresence,  which  first  invades  the 
fornix  and  then  extends  downward  toward  the  vulva.  It  appears,  in  some  cases, 
to  have  its  origin  in  the  neighborhood  of  plaques  of  chronic  vaginitis. 

2.  Nodular  or  infiltrated  form.  This  appears  as  nodules,  which  rapidly  become 
confluent.  The  growth  is  sometimes  localized  about  the  wall  of  the  urethra,  giving 
rise  to  a  well-defined  clinical  type  known  as  "periurethral  cancer."  Ulceration 
here  advances  rapidly. 

In  primary  cancer  of  the  vagina,  as  in  cancer  elsewhere,  a  positive  diagnosis  in 
the  early  stage  must  rest  upon  the  microscopic  findings  in  an  excised  piece.  The 
treatment  is  complete  extirpation,  if  seen  early  enough.  The  results  thus  far  have 
been  unsatisfactory.  There  is  usually  recurrence.  However,  it  is  probable  that 
the  adoption  of  recent  radical  operations  looking  to  the  extirpation,  not  only  of  the 
infiltrated  area  but  of  all  surrounding  tissues  likely  to  be  involved,  will  give  much 
better  results,  at  least  in  the  early  cases.  Also  by  special  apparatus  X-ray  treat- 
ment and  Actinic-ray  treatment  may  aid  some  in  preventing  recurrence. 

Chorio-Epithelioma.  This  variety  of  carcinoma  sometimes  occurs  in  the 
vagina.  This  curious  form  of  tumor  will  be  considered  in  greater  detail  under 
Malignant  Disease  of  the  Uterus.  It  arises  from  chorionic  villi  and  may  develop 
after  normal  parturition  or  after  abortion  or  after  mole-pregnancy.  It  usually 
develops  in  the  uterus,  but  occasionally  one  of  the  chorionic  villi  transported  to 
the  vagina  (pieces  of  chorionic  villi  are  normally  transported  to  various  parts  of 
the  body  in  probably  all  pregnancies)  takes  on  the  peculiar  change  and  forms  a 
malignant  growth.  As  it  grows,  it  breaks  into  the  veins,  causing  miniature  hema- 
tomata  in  the  vicinity.  As  this  kind  of  tumor  usually  causes  metastases  through 
the  body,  with  rapid  death,  it  is  important  to  recognize  and  remove  it  at  the 
earliest  possible  moment.     Such  a  growth  in  the  vagina  or  in  the  vulva  is  usually 


436  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

metastatic  from  a  similar  growth  in  tlie  uterus,  hence  the  condition  of  the  uterus 
should  be  investigated. 

Sarcoma.  One  form  in  which  sarcoma  of  the  vagina  occurs,  is  as  a  diffuse  infil- 
tration and  degeneration  of  the  lining  membrane.  This  is  the  form  sometimes 
found  in  young  children.  It  occurs  most  frequently  in  the  posterior  vaginal  wall. 
It  begins  as  a  small  indurated  area  which  slowly  increases  in  size.  After  a  time  the 
epithelium  covering  the  area  is  lost  and  an  ulcer  forms.  The  ulcer  bleeds  easily 
and  is  surrounded  by  an  area  of  induration.  A  large  part  of,  or  even  the  entire 
circumference  of  the  vagina  may  become  involved  in  the  sarcomatous  infiltration, 
which  may  be  mistaken  for  carcinoma  or  tuberculosis. 

The  symptoms  of  sarcoma  of  the  vagina  are  leucorrhoea,  hemorrhage,  pain  and 
obstruction  of  the  vagina  by  the  infiltration.  Slight  hemorrhage  may  appear  in 
the  early  stages,  particularly  after  coitus  or  exertion.  In  the  late  stages,  profuse 
hemorrhages  occur  and  there  is  also  a  muco-purulent  or  watery  discharge  that  may 
cause  much  pruritis.  The  pain  is  slight  at  first  but  gradually  increases  in  severity. 
It  is  usually  worse  at  night.  Examination  reveals  a  nodular  tumor  or  an  area  of 
induration  or  ulceration  and  more  or  less  narrowing  or  obstruction  of  the  vagina. 
For  a  positive  diagnosis  of  the  nature  of  the  growth  a  microscopic  examination  of  a 
section  of  tissue  is  necessary.     The  treatment  is  the  same  as  for  carcinoma. 

ULCUS  RODENS  VULVAE. 

From  the  large  group  of  affections  formerly  classified  roughly  undef  the  terms 
"rodent  ulcer,"  "lupus,"  "esthiomene,"  "perforating  ulcer"  and  similar  names, 
there  have  been  cut  out  distinct  classes,  until  now  these  cases  are  pretty  well  di- 
vided up  as  syphilis,  tuberculosis  (to  which  the  term  lupus  is  now  restricted)  and 
malignant  disease,  with  special  characteristics  for  each.  There  still  remain,  how- 
ever, certain  persistent  destructive  ulcers  whose  etiology  is  not  definitely  known, 
and  consequently  whose  etiological  classification  can  not  yet  be  positively  made. 
They  are  not  syphilitic  nor  tubercular  nor  malignant. 

They  constitute  a  class  by  themselves  and,  in  the  absence  of  more  definite  infor- 
mation, are  very  appropriately  designated  by  the  non-committal  term  "ulcus 
rodens"*  (gnawing  ulcer). 

Rodent  ulcer  of  the  vulva  may  be  defined  as  a  destructive  chronic  ulcer  that  is 
not  syphylitic  nor  tubercular  nor  malignant. 

The  affection  occurs  almost  exclusively  in  prostitutes  and  is  apparently  due  to 
the  combination  of  depressed  general  health  and  the  chronic  irritation  of  frequent 
coitus  (traumatism)  and  varied  and  repeated  infections  and  uncleanliness.  The 
post-syphilitic  state  is  undoubtedly  an  important  etiological  factor  in  many  cases, 
the  effect  being  due  prolmbly  to  the  deteriorated  general  health  and  lowered  tissue 
resistance.  Real  .syphilitic  lesions,  i.  e.  those  yielding  to  antisyphilitic  treatment, 
are  excluded  by  the  terms  of  the  definition  of  rodent  ulcer,  the  clinical  differentia- 
tion being  aided  by  the  therapeutic  test.  The  cicatricial  tissue  which  forms  around 
and  under  the  ulcerated  area  tends  further  to  interfere  locally  with  nutrition, 

*  This  must  not  be  confounded  with  the  "ulcus  rodens"  of  the  face,  which  is  a  definite  and 
peculiar  variety  of  epithelial  cancer. 


ULCER  RODEN   VULVAE  437 

The  pathological  changes  are  those  found  in  chronic  ulceration  with  cicatrical 
change,  but  without  any  of  the  special  characteristics  found  in  syphilitic,  tuber- 
cular or  malignant  ulcers.  There  is  the  granulating  surface,  the  round-cell  infil- 
tration and  the  connective  tissue  hyperplasia.  The  ulceration  often  extends  deeply 
into  the  structures  in  various  directions  and  causes  perforations  and  fistulae.  As 
it  spreads  at  one  part  it  heals  at  another,  thus  forming  scar-tissue.  The  contrac- 
tion of  this  scar-tissue  and  of  the  inflammatory  infiltration  under  the  ulcer  causes 
more  or  less  interference  with  the  lymph  circulation.  If  the  trouble  persists  for 
years,  as  it  sometimes  does,  there  is  very  likely  to  be  stasis  hypertrophy. 

Symptoms  and  Diagnosis.  The  patient  complains  usually  of  leucorrhoea  and 
of  burning  on  urination  and  of  pain  on  coitus.  There  are  frequently  evidences  ot 
irritation  of  the  bladder  or  of  the  rectum.  If  the  ulcer  has  penetrated  deeply 
enough  there  may  be  incontinence  of  urine  or  feces.  In  some  cases  there  is  pain  on 
walking  or  sitting,  while  in  other  cases,  even  with  extensive  ulceration,  the  patient 
has  but  little  pain.  In  many  cases  the  ulceration  is  accompanied  with  stasis 
hypertroph}'-,  and  in  such  cases  there  is  nearly  always  considerable  skin 
irritation.  This  is  increased  by  uncleanliness  and  by  the  decomposition  of  the 
discharge  in  the  folds  and  depressions  of  the  hypertrophied  structures. 

Examination  shows  the  ulceration,  with  or  without  stasis  hypertrophy.  A  com 
mon  site  for  the  ulceration  is  about  the  vestibule  and  extending  up  into  the  vagina 
In  some  cases  it  extends  deeply  into  the  urethra,  separating  the  lower  urethral  wall 
so  that  it  is  simply  a  flap,  which  falls  away  from  the  upper  wall.  This  destructive 
ulceration  may  extend  to  the  neck  of  the  bladder  and  cause  incontinence  of  urine. 
If  the  ulceration  appears  at  the  posterior  part  of  the  vulva  it  may  penetrate  into 
the  rectum  and  cause  a  recto-vaginal  fistula. 

In  the  examination,  it  is  important  to  separate  the  swollen  structures  and  trace 
the  ulcer  in  all  its  ramifications.  Sometimes  there  are  two  or  more  ulcerated  areas, 
and  also  spots  of  dermatitis  due  to  the  irritation  of  the  discharge.  If  the  manipu- 
lations cause  too  much  pain  to  permit  of  a  thorough  examination,  apply  some 
20%  cocaine  solution  to  the  painful  areas.  Rodent  ulcers  usually  bleed  but  little 
from  the  ordinary  manipulations — not  nearly  so  frequently  nor  so  freely  as  malig- 
nant ulcerations. 

From  rodent  ulcer  we  must  distinguish  the  simple,  chancroidal,  syphilitic, 
tubercular  and  malignant  ulcers. 

In  simple  ulceration,  there  is  usually  some  cause  apparent,  and  the  ulcer  heals 
promptly  on  removal  of  the  cause  and  the  maintenance  of  cleanliness  and  the  use 
of  some  mild  antiseptic  or  astringent. 

In  chancroid,  the  ulcer  is  acute  and  presents  the  characteristics  previously 
described  for  chancroid,  and  there  may  be  a  history  of  suspicious  coitus  followed  in 
a  few  days  by  the  painful  ulcer  which  rapidly  enlarges.  Cauterization  and  the 
other  treatment  recommended  for  chancroid  leads  to  prompt  healing. 

Tertiary  syphilis  often  leads  to  destructive  ulceration  which  very  much  reseml)les 
rodent  ulcer.  But  there  are  usually  other  evidences  of  active  syphilis,  and  the 
lesion  is  much  benefitted  by  antisyphilitic  treatment. 

Tuberculosis  of  the  vulva,  in  some  cases,  causes  deep  and  persistent  ulceration 
which  is  much  Uke  rodent  ulcer.     But  the  special  characteristics  given  under 


438  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

tubercular  ulcer  are  present,  also  microscopic  examination  of  excised  tissue  or  of 
pus  and  scrapings  from  the  ulcer  will  show  the  trouble  to  be  tubercular. 

Malignant  disease  is  characterized  by  the  tendency  to  bleed  on  slight  manipulation 
and  by  an  area  of  induration  about  the  ulcer.  In  a  doubtful  case  a  piece  of  the 
margin  of  the  ulcer  should  be  excised  under  cocaine  for  microscopical  examination. 

Treatment.  The  measures  recommended  under  simple  ulcers  should  be  carried 
out  and  should  be  supplemented  by  general  tonic  treatment  to  build  up  the  tissue 
resistance.  In  addition  to  this,  practically  every  case  of  this  kind  should  receive 
a  thorough  course  of  iodides,  both  for  diagnostic  purposes  and  for  therapeutic  effect. 
Very  few  cases  of  rodent  ulcer  are  much  benefitted  by  the  iodides  but  occasionally 
one  is  considerably  benefitted.  Other  measures  are  mild  cauterizations,  deeper 
cauterization  and  other  measures  mentioned  under  chancroid.  The  X-ray  treat- 
ment sometimes  produces  prompt  healing.  A  very  important  point  in  the  treat- 
ment is  rest  of  the  parts.  To  secure  this  there  must  be  no  sexual  intercourse  and 
no  unnecessary  walking  or  standing. 

URETHRITIS. 

Inflammation  of  the  urethra  and  also  of  the  urethral  ducts  (Skene's  glands) 
have  already  been  considered,  under  Gonorrhoea. 

PERIURETHRAL  ABSCESS. 

This  term  is  applied  to  an  abscess  situated  outside  of  the  urethra  but  due  to 
infection  from  the  urethra.  It  usually  lies  between  the  urethra  and  vagina.  The 
pocket  of  pus  may  or  may  not  communicate  with  the  urethra.  This  condition  is 
known  also  as  "urethrocele,"  ''sacculation  of  urethra,"  "sinus  of  urethra," 
"urethral  diverticulum"  and  "suburethral  abscess." 

Etiology  and  Pathology.  In  some  cases  there  is  infection  of  a  urethral  gland 
which  becomes  somewhat  obstructed  and  dilated  with  pus  and  is  accompanied  with 
considerable  inflammation  and  infiltration  and  pus  formation  outside  the  gland. 
In  other  cases  there  is  probably  first  either  a  congenital  cyst  or  a  cyst  formed  by 
obstruction  of  the  duct  of  one  of  the  urethral  glands  which  becomes  markedly  di- 
lated by  accumulating  secretion.  Later  there  is  infection  of  the  cyst  by  rupture  or 
otherwise,  and  consequent  abscess.  It  is  supposed  also  that  injuries  in  labor  ma}" 
lead  to  localized  dilation,  sacculation  and  suppuration. 

In  either  case,  as  the  collection  of  fluid  increases  in  size  a  swelling  appears  in  the 
anterior  vaginal  wall  below  the  urethra  (Fig.  285).  In  some  cases  the  vaginal  wall 
over  the  swelling  is  normal,  while  in  other  cases  there  is  much  infiltration  and 
thickening  and  induration.  The  abscess  frequently  ruptures  into  the  urethra  and 
empties  itself  incompletely.  It  may  continue  for  weeks  or  months  partially  filled 
with  pus  and  decomposing  urine,  and  discharging  through  a  small  opening.  In 
other  cases  there  seems  little  or  no  active  inflammation  and  no  discharging  sinus, 
.simply  a  collection  of  fluid  resembling  a  cyst.  In  such  a  case  there  may  be  simply 
a  retention  cyst  without  infection  or  there  may  have  been  an  infection  that  died 
out  without  forming  pus. 

Symptoms  and  Diagnosis.     When  there  is  an  acnitc  aljsccss,  there  are  all  the  ordi- 


URETHRAL  AFFECTIONS  439 

nary  evidences  of  inflammation  with  urethral  irritation  added,  causing  frequent 
painful  urination.  In  some  cases  there  still  remain  evidences  of  the  urethritis  that 
was  responsible  for  the  periurethral  infection.  There  is  a  reddened  tender  indurate<  I 
swelling  of  the  anterior  vaginal  wall  under  the  urethra.  The  swelling  and  indura- 
tion may  be  diffuse  or  circumscribed.  If  a  collection  of  pus  of  any  size  has  formed 
there  will  be  fluctuation.  If  the  abscess  has  opened  into  the  urethra,  pressure  on 
the  swelling  will  cause  pus  to  flow  into  the  urethra  and  out  at  the  meatus.  Some- 
times a  probe  may  be  passed  from  the  meatus  through  the  opening  into  the  peri- 
urethral cavity  (Fig.  286). 

When  the  acute  inflammation  has  subsided,  there  is  left  simply  a  swelling  with 
considerable  urethral  irritation.  If  the  cavity  is  discharging  into  the  urethra,  the 
swelling  may  have  largely  disappeared.  Such  a  pocket  outside  the  urethra  may 
cause  urethral  and  l)ladder  disturbance  for  months  without  the  real  condition  Vjeing 
suspected,  particularly  if  there  is  simply  a  sinus  or  small  pocket  with  but  little 
swelling.  It  ma}-  keep  up  a  urethritis  indefinitely  and,  if  gonorrhoeal,  the  patient 
is  capable  of  communicating  the  infection  as  long  as  the  sinus  exists.  An  exac- 
cerbation  of  the  inflammation  with  acute  symptoms  may  come  on  at  any  time. 
Such  a  periurethral  sinus  may  be  the  unsuspected  cause  of  the  persistent  presence 
of  pus  in  the  urine. 

Treatment.  The  treatment  for  this  condition  is  to  drain  the  cavity  at  the  most 
dependent  part,  that  is,  where  it  comes  closest  to  the  vaginal  wall.  At  this  point 
a  large  opening  should  be  made  and  the  incision  should  be  kept  open  by  gauze 
packing  or  a  drainage  tube  until  the  cavity  heals  from  the  bottom.  The  abscess 
cavity  should  be  washed  out  with  hydrogen  peroxide  and  given  the  usual  treatment 
of  a  suppurating  cavity.  When  drainage  is  free  below,  the  opening  into  the  urethra 
usually  closes  prompty. 

When  there  is  only  a  collection  of  fluid  without  active  inflammatory  symptoms, 
the  small  cyst  thus  formed  may  be  extirpated.  In  extirpation  of  such  a  mass, 
care  should  be  exercised  not  to  dissect  too  close  to  the  urethra  nor  to  the  sphincter 
at  the  neck  of  the  bladder.  In  either  situation  it  is  better  to  leave  part  of  the  cyst 
wall  than  to  injure  the  important  structures  adjacent  thereto.  When  there  is  simply 
a  sinus  or  small  pocket  communicating  with  the  urethra  by  a  fairly  large  opening 
near  the  meatus,  the  plan  may  be  tried  of  treating  the  cavity  with  various  anti- 
septics such  as  hydrogen  peroxide,  iodoform  in  glycerine  (10%)  oi"  silver  nitrate 
solution  {i%  to  2%),  injected  into  the  cavity  by  way  of  the  meatus  through  a 
small  tube  such  as  the  Eustachian  catheter.  If  this  fails,  then  the  external  in- 
cision and  drainage  is  to  be  employed. 

PROLAPSE  OF  URETHRAL  MUCOSA. 

This  affection  is  known  also  as  "procidentia  urethrae."  It  consists  of  a  pro- 
lapse of  the  urethral  mucous  membrane,  accompanied  by  more  or  less  prolifera- 
tion of  the  submucous  connective  tissue. 

Symptoms  and  Diagnosis.  The  red  projecting  membrane  sun-ounds  the  meatus 
(Fig.  283).  It  often  bleeds  easily  and  is  somewhat  sensitive  to  the  touch,  though 
not  nearly  so  sensitive  as  a  caruncle.  It  usually  gives  rise  to  considerable  irri- 
tation, with  frequent  painful  urination  and  some  discharge.     It  is  distinguished 


440  DISEASES  OF  EXTERNAL  GEXITALS  AND  VAGINA 

from  polypus  and  caruncle  by  the  fact  that  it  surrounds,  or  almost  surrounds,  the 
meatus. 

Marked  prolapse  of  the  urethral  mucosa  is  not  a  common  affection,  though  sHghfc 
gaping  of  the  urethra,  through  which  the  mucous  membrane  may  be  seen,  is  very 
common  in  women  who  have  had  urethritis  or  have  passed  through  several  labors. 

Treatment.  If  symptoms  are  absent  or  slight,  no  treatment  is  necessary.  If 
the  prolapse  is  marked  enough  to  be  troublesome,  the  part  may  be  cocainized,  or 
the  patient  anesthetized,  and  the  redundant  portion  of  mucous  membrane  excised 
and  the  wound  closed  by  sutures.  It  is  convenient  to  pass  the  sutures  first,  then 
excise  the  tissue,  then  tie  the  sutures.  This  prevents  the  inner  edge  from  retracting 
out  of  reach.  The  sutures  should  be  placed  close  enough  together  to  close  the 
wound  and  prevent  hemorrhage. 

Another  good  method  of  excision  is  to  begin  at  one  side  and  divide  the  tissues  for 
a  short  distance  and  immediately  close  the  resulting  wound  by  suture,  continuous 
or  inteiTupted  as  preferred.  Another  portion  is  then  divided  and  the  wound  closed 
as  before.  This  process  is  continued  until  the  redundant  tissue  is  removed  all  the 
way  around.  This  prevents  hemorrhage,  prevents  retraction  and  secures  good 
approximation.  Clean  excision  ^dth  the  knife  or  scissors  followed  by  immediate 
suture  of  the  wound  is  decidedly  preferable  to  cautery  amputation.  Fine  catgut 
is  the  preferable  suture  material. 

URETHRAL  CARUNCLE. 

Urethral  caruncle  is  a  small  papillary  growth  occurrmg  about  the  meatus,  most 
frequently  near  the  low^er  portion.  It  is  usually  very  sensitive  and  often  gives  rise 
to  excruciating  pain  on  urination.  It  is  known  also  as  "irritable  caruncle"  and 
"urethral  angioma."  The  cause  of  urethral  caruncle  is  not  known.  Probably 
chronic  inflammation  of  Skene's  glands  has  some  influence  in  its  causation,  as  it 
usually  occurs  in  the  neighborhood  of  the  gland  openings.  Inflammation  of  the 
urethra,  particularly  gonorrhoeal  inflammation,  is  supposed  to  be  a  causative 
factor. 

The  little  tumor  is  essentially  a  vascular  gi-owth.  Skene,  who  made  a  special 
study  of  urethral  neoplasms,  applied  to  caruncle  the  term  "papillary  polypoid 
angioma"  and  gave  the  following  description.  "It  consists  of  a  bunch  of  dilated 
capillaries,  set  in  a  moderately  dense  stroma  of  connective  tissue,  covered  vAth. 
mucous  membrane  which  has  the  usual  pavement  epithelium.  One  case,  however, 
is  recorded  where  the  pavement  was  replaced  by  columnar  epithelium.  The  vessels 
are  greatly  dilated  and  in  some  cases  very  tortuous,  while  in  others  less  so." 

The  growth  is  seen  as  a  deep  red  mass  at  the  meatus  (Fig.  284)  or  just  within  the 
canal.  It  is  sensitive  when  touched  and  may  bleed  easily  on  manipulation.  It 
may  have  a  distinct  pedicle  or  a  broad  l)ase.  Usually  there  is  but  one  gi-owth,  but 
sometimes  there  are  two  or  more. 

Symptoms  and  Diagnosis.  The  principal  s3'mptom  is  pain  on  urination.  It  may  be 
slight  or  it  may  be  very  severe.  In  some  cases  the  pain  is  so  troublesome  that  the 
patient  will  hold  the  urine  as  long  as  possible,  to  avoid  the  suffering  caused  by  pass- 
ing it.     Walking  may  cause  pain  as  may  also  pressure  of  any  kind,  even  contact 


VtTLVO-VAGINAL  GLAND  AFFECTIONS  441 

of  the  clothing.  Imtability  of  the  bladder,  as  indicated  by  frequent  urination,  is 
usually  present.  Occasionally  retention  of  urine  is  caused  by  reflex  spasm.  Pain 
and  hemorrhage  may  be  caused  by  sexual  intercourse,  and  in  some  cases  coitus  is 
impossible.  The  patient's  general  health  necessarily  suffers  from  the  constant 
irritation  and  she  becomes  nervous,  irritable  and  despondent. 

Polypi  of  the  urethral  mucous  membrane  and  prolapsed  mucous  membrane 
differ  from  caruncle  in  being  less  vascular  and  less  sensitive.  Also,  polypi  are 
attached  higher,  while  in  prolapse  of  the  mucous  membrane  the  base  of  the  mass 
includes  the  larger  part,  if  not  all  of  the  circumference  of  the  meatus  (Fig.  283). 

Treatment.  The  treatment  for  caruncle  is  removal.  First  apply  a  small  piece 
of  absorbent  cotton  soaked  in  cocaine  solution(20%)  and  leave  in  place  five  minutes. 
Then  with  a  hypodermic  syringe  inject  several  drops  of  a  weaker  cocaine  solution 
{h%)  under  the  base  of  the  gi'owth  and  wait  a  few  minutes  longer.  Then  clip  the 
growth  off  with  scissors.  All  the  abnormal  tissue  must  be  removed.  Then  intro- 
duce one  or  more  fine  catgut  sutures,  close  the  wound  and  stop  the  hemorrhage. 

If  the  base  is  small  and  the  resulting  wound  slight  and  without  much  hemor- 
rhage, it  may  be  simply  touched  with  carbolic  acid  or  liquor  ferri  subsulphatis, 
no  sutures  being  needed.  When  the  growth  has  a  broad  base  and  the  patient  is  very 
nervous  or  hysterical  it  may  be  necessary  to  give  a  general  anesthetic.  In  some 
cases,  anesthesia  is  required  for  other  reasons,  for  example,  a  thorough  pelvic  ex- 
amination or  curetment  or  repair  of  pelvic  floor,  and  in  such  a  case  the  cai  uncle 
may  be  taken  care  of  at  the  same  time.  The  urethral  and  bladder  irritation 
usually  subsides  rapidly  after  the  growth  is  removed. 

While  the  patient  is  waiting  for  operation,  some  temporary  relief  may  be  given 
by  the  frequent  appHcation  of  cocaine  solution  (5%  to  10%). 

INFLAMMATION  OF  VULVO=VAQINAL  GLAND. 

Inflammation  of  the  duct  of  the  vulvo-vaginal  gland  and  of  the  gland  proper, 
has  been  considered  under  Gonorrhoea.  Inflammation  in  this  gland  of  Bartholin 
is  sometimes  referred  to  as  "Bartholinitis." 

ABSCESS  OF  VULVO=VAQINAL  GLAND. 

The  cause  is  infection  with  the  gonococcus  or  the  ordinary  pus  germs.  The 
first  is  by  far  the  more  frequent,  and  the  gonorrhoeal  inflammation  often  persists  in 
the  gland  long  after  the  vaginal  inflammation  has  disappeared. 

The  infection  enters  at  the  mouth  of  the  duct  and  progresses  along  the  duct  to 
the  gland  proper.  The  secretion  of  the  gland  is  increased,  the  duct  becomes  ob- 
structed and  a  collection  of  pus  forms,  distending  the  gland  and  pointing  in  the 
direction  of  least  resistance.  Sometimes  the  duct  alone  is  involved,  the  gland 
proper  escaping.  This  is  indicated  by  the  swelling  being  small  and  confined  to  the 
region  of  the  duct. 

Symptoms  and  Diagnosis.  The  symptoms  are  a  painful  swelling  at  the  side  of  the 
vaginal  opening  with  some  fever.  Examination  reveals  a  swelling  the  size  of  a 
small  egg  situated  in  the  tissues  at  one  side  of  the  vaginal  orifice  and  projecting 
beyond  the  median  line  (Figs.  264,  265).     The  swelling  is  tender  on  pressure  and  is 


442  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

red  and  hot.  Fluctuation  is  distinct  and  the  fluid  seems  near  the  surface. 
The  orifice  of  the  duct  may  be  seen,  but  a  probe  will  not  enter  the  gland  because  the 
duct  is  obstructed.  If  the  obstruction  is  so  slight  that  it  gives  way  before  the 
probe,  then  pus  is  discharged  through  the  duct. 

The  following  conditions  may  be  confounded  with  abscess  of  the  vulvo-vaginal 
gland. 

Cyst  of  Vulvo- Vaginal  Gland.  This  is  a  chronic  affair,  the  patient  usually 
giving  a  history  of  the  swelling  having  been  there  for  a  long  time  and  the  inflam- 
matory signs  (heat  and  pain  and  redness)  are  absent. 

Pudendal  Hernia.  This  must  always  be  taken  into  consideration  in  determining 
the  character  of  a  swelling  of  the  vulva.  Hernia  presents  one  or  more  of  the  hernial 
signs,  such  as  impulse  on  coughing,  reducibility,  intestinal  obstruction,  resonance 
on  percussion.  The  first  evidence  of  hernia  is  usually  noticed  at  once  after  some 
straining  effort  or  injury,  much  more  promptly  than  either  abscess  or  cyst  would 
appear. 

Tumor  of  Labia.  This  differs  from  abscess  in  the  al^sence  of  inflammation  and 
fluctuation,  in  growing  slowly  and  in  presenting  the  signs  that  distinguish  the  var- 
ious kinds  of  vulvar  tumors. 

Treatment.  Open  the  abscess  freely  by  an  incision  where  the  pus  is  nearest  the 
surface,  wash  out  the  cavity  with  hydrogen  peroxide  and  pack  with  antiseptic 
gauze.  The  wound  should  be  dressed  the  next  day  and  as  frequently  thereafter  as 
is  necessary  to  keep  it  clean.  Care  must  be  taken  that  a  good  sized  piece  of  gauze 
projects  into  the  cavity,  that  the  edges  of  the  incision  may  be  kept  separated  until 
the  cavity  gi-anulates  from  the  bottom.  If  the  incision  into  the  abscess  is  not  made 
when  the  patient  is  first  seen,  but  is  postponed  to  another  day,  much  relief  in  the 
meantime  may  be  obtained  from  the  application  of  a  hot  poultice.  Direct  the 
patient  to  take  a  large  thick  piece  of  absorbent  cotton,  wring  it  out  of  very  hot 
water  and  apply  it  immediately  to  the  inflamed  structures  and  cover  it  with  a 
piece  of  oiled-silk.  This  hot  moist  dressing  may  be  held  in  place  with  a  T-bandage. 
It  may  be  renewed  as  soon  as  it  begins  to  cool,  if  the  pain  is  troublesome. 

SINUS  OF  VULVO=VAQINAL  GLAND. 

In  many  cases  of  abscess  of  the  gland,  after  the  pus  is  discharged  the  cavity 
closes  entirely  and  there  is  permanent  cure.  In  other  cases  a  sinus  persists,  giving 
rise  to  a  constant  slight  discharge.  The  outer  end  of  the  sinus  may  close  and  a 
reaccumulation  of  pus  take  place,  forming  another  abscess.  This  may  be  repeated 
several  times  in  the  course  of  a  few  years.  Again,  in  inflammation  of  the  vulvo- 
vaginal gland,  the  duct  may  remain  open  giving  exit  to  the  pus  as  it  forms  and 
constituting  a  sinus  or  discharging  tract. 

The  diagnosis  of  sinus  of  the  vulvo-vaginal  gland  is  made  by  the  history  of 
inflammation  of  the  gland  associated  with  a  sinus  in  that  locality.  By  palpating 
the  gland  (Fig.  51),  it  can  often  be  felt  as  a  small  hard  lump,  indicating  infiltration 
and  enlargement.  Pressure  on  this  lump  will  sometimes  cause  pus  to  flow  from 
the  sinus.  A  small  probe  introduced  into  the  sinus  passes  into  the  region  of  the  gland. 

Treatment.  If  the  sinus  has  a  goorl-sizcd  external  opening  and  has  been  present 
only  a  few  weeks,  it  may  close  if  washed  out  daily  with  hydrogen  peroxide.     The 


CYST  OF  VULVO-VAGINAL  GLAND  443 

peroxide  should  be  forced  to  the  bottom  of  the  sinus  and  it  may  be  followed  by 
iodoform  in  glycerine  (10%)  or  argyrol  (25%)  or  protargol  (5%  to  10%)  or  silver 
nitrate  solution  (2%  to  5%).  In  most  cases  however  the  only  way  to  effect  a  per- 
manent cure  is  to  extirpate  the  sinus  tract  and  the  infiltrated  gland. 

This  is  a  small  operation,  but  the  patient  will  usually  require  a  general  anesthetic, 
for  considerable  dissection  is  necessary.  The  parts  are  very  vascular  and  there  is 
much  oozing.  The  resulting  cavity  is  closed  with  sutures.  The  sutures  serve  also 
to  stop  the  bleeding  and  ligatures  are  seldom  necessary.  Quite  a  depression  is  left 
where  the  inflamed  gland  was  situated.  This  depression  is  not  of  particular  im- 
portance and  in  time  becomes  less  pronounced.  It  is  well,  however,  to  mention  to 
the  patient  before  operation  that  a  small  depression  will  be  left  when  the  inflamed 
gland  is  removed. 

When  beginning  the  operation,  in  addition  to  the  usual  antiseptic  measures,  the 
sinus  should  be  washed  out  thoroughly  with  peroxide  and  then  with  bichloride, 
During  the  operation,  care  must  be  exercised  to  avoid  contaminating  the  cut  sur- 
faces with  pus  from  the  sinus.  The  object  is  to  remove  all  the  infected  tissue  and 
secure  union  of  the  wound  by  first  intention. 

CYST  OF  VULVO=VAQINAL  GLAND. 

A  cyst  of  the  vulvo-vaginal  gland  is  due  to  an  obstruction  of  the  duct,  with  accu- 
mulation of  secretion  in  the  gland  causing  it  to  become  dilated.  In  some  cases  of 
inflammation,  gonorrhoeal  or  otherwise,  cyst  of  the  gland,  instead  of  abscess, 
results.  The  cyst  appears  as  a  fluctuating  swelling  in  the  region  of  the  gland 
(Fig.  266). 

The  swelling  is  not  painful  and  the  skin  may  be  moved  freely  over  it.  The  form 
and  location  of  the  swelling  is  like  that  of  abscess,  but  none  of  the  acute  inflam- 
matory symptoms  are  present.  Sometimes  the  duct  only  is  the  seat  of  the  cyst. 
In  that  case  the  swelling  is  small  and  is  situated  at  some  part  of  the  course  of  the 
duct. 

The  only  affection  that  is  liable  to  be  confounded  with  this  cyst  is  pudendal 
hernia.  The  distinguishing  characteristics  of  hernia  are  marked  increase  of  the 
trouble  on  straining,  obstructive  bowel  disturbance,  impulse  in  the  mass  on 
coughing,  tympanitic  percussion  note  over  the  mass  (if  containing  bowel)  and 
the  possibility  of  partial  or  complete  reduction  into  the  peritoneal  cavity. 

Treatment.  An  attempt  may  be  made  to  secure  obliteration  of  the  cyst  without 
a  cutting  operation.  Cleanse  the  inner  side  of  the  cyst  and  introduce  the  needle  of 
a  small  aspirator  or  a  hypodermic  syringe  and  draw  off  the  contents  as  com- 
pletely as  possible. 

The  labia  minora  and  the  tissues  lying  to  the  outer  and  anterior  part  of  the  cyst 
are  full  of  veins  and  must  be  avoided.  The  bulb  of  the  vestibule  also,  which  lies 
against  the  upper  end  of  the  cyst,  should  be  avoided.  If  the  needle  is  introduced 
through  any  of.  these  structures  a  troublesome  hematoma  may  result.  Con- 
quently  all  punctures  of  the  cyst  should  be  made  at  its  inner  and  lower  portion, 
just  at  the  margin  of  the  vaginal  mucous  membrane  where  the  intervening  tissues 
are  thin  and  comparatively  free  from  veins. 


444  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

After  the  evacuation  of  the  cyst,  a  pad  of  cotton  or  gauze  should  be  appUed  over 
it  and  held  firmly  against  it  by  a  T-bandage.  As  soon  as  the  patient  reaches  home 
she  should  go  to  bed  and  remain  there  for  two  or  three  days,  keeping  the  bandage 
applied  firmly.  If  swelling  or  pain  appears,  elevate  the  hips  on  a  pillow  and  apply 
an  ice-bag. 

If  the  cyst  refills,  the  contents  may  again  be  drawn  off  and  some  irritating  fluid 
injected  into  the  cavity  as  in  the  injection  treatment  for  ordinary  hydrocele. 

There  are  two  cutting  methods.  One  method  is  to  open  the  cyst  on  the  inner 
side,  cut  out  some  tissue  on  each  side  of  the  incision,  so  that  it  will  not  close  so 
easily,  curet  the  inner  surface  of  the  sac  and  pack  with  antiseptic  gauze.  The 
external  wound  is  kept  open  until  the  cavity  is  obliterated.  In  this  method  the 
treatment  is  prolonged  and  a  sinus  may  result. 

The  other  method  is  to  extirpate  the  cyst.  In  extirpating  the  cyst,  avoid  cut- 
ting into  it  if  possible,  as  it  is  much  easier  enucleated  when  distended  than  when 
collapsed.  The  resulting  cavity  is  closed  with  sutures.  This  method  is  the  on-e  of 
choice  from  the  very  first  in  all  cases  in  which  there  is  no  contra-indication  to  general 
anesthesia. 

When  the  patient  is  not  in  good  condition  for  a  general  anesthetic,  the  cyst  may 
in  some  cases  be  extirpated  by  injecting  a  considerable  quantity  of  a  weak  cocaine 
solution  (1%  to  J%)  or  the  Schleich  solution  No.  2  (See  Formulae)  around  the  cyst 
and  under  it  (infiltration  method) .  This  will  do  away  with  the  greater  part  of  the 
pain.  To  facilitate  the  dissection  in  such  cases,  Pozzi  adopted  the  very  ingenious 
plan  of  filling  the  cyst  with  paraffin.  The  cyst  is  first  punctured  and  the  fluid 
drawn  off.  The  cavity  is  then  washed  out  with  hot  water  and  the  melted  paraffin 
is  introduced  at  a  low  temperature.  When  the  cavity  is  distended,  ice  is  applied 
and  in  a  few  minutes  there  is  formed  a  solid  mass,  which  is  extirpated  under  the 
anesthesia  of  the  cold  and  cocaine. 

CONDYLOMATA  OF  VULVA. 

Condylomata  are  small  non-malignant  growths  occurring  about  the  vulva. 
There  are  three  varieties. 

1.  The  common  wart,  called  also  "verruca  vulgaris." 

2.  The  pointed  condyloma,  called  also  "condyloma  acuminata,"  "venereal 
wart"  and  "moist  wart." 

3.  The  flat  condyloma,  called  also  "  condyloma  lata. " 

Etiology,  Pathology,  Symptoms.  The  common  wart  occurs  rather  frequently 
about  the  vulva.  It  is  usually  situated  on  the  labia  majora  or  mons  veneris.  The 
particular  cause  for  it  is  not  known.  It  is  dr-^-  and  sometimes  much  pigmented,  but 
rarel"  causes  any  disturbance. 

T  pointkd  coxdvloma  or  moist  wart  ^'-cnrs  on  those  parts  of  the  vulva  whic-h 
are  quently  moist,  namely,  the  "^  osblbule,  the  vaginal  entrance,  the  labia  minora, 
the  rineum  and  about  the  anus.  In  some  cases  they  occur  on  the  labia  majora 
and  even  on  the  thighs. 

Tliey  are  usually  associated  with  venereal  disease  but  not  necessarily  so.  They 
are  small  pointed  papillary  masses  with  a  thin  covering  of  epithelium.     They  occur 


CONDYLOMATA  OF  THE  VULVA  445 

singly  or  in  groups  or  in  large  numbers  (Figs.  257,  258).  They  may  vary  in  size 
from  the  head  of  a  pin  to  a  large  cauliflower  mass  covering  half  or  more  of  the  vulva 
(Figs.  259,  200). 

They  are  due  to  some  irritating  discharge,  usually  gonorrhoeal.  Sometimes  they 
are  due  to  a  simple  discharge  as,  for  example,  the  increased  vaginal  flow  of  preg- 
nancy. When  present  during  pregnancy  they  grow  very  rapidly.  Whenever  they 
are  found,  a  careful  search  should  be  made  for  evidences  of  previous  gonorrhoea. 

Usually  condylomata  are  not  particularly  painful  nor  tender.  In  some  cases  they 
become  inflamed  and  are  then  painful  and  may  bleed  easily.  When  the  condy- 
lomata are  multiple  and  grouped  together  in  large  masses  (Fig.  259),  secretion  is 
liable  to  lie  in  the  interstices  of  the  gi-owth  and  become  decomposed,  giving  rise  to 
an  offensive  odor  and  considerable  irritation.  If  situated  near  the  meatus,  con- 
siderable liladder  irritability  may  result. 

The  FLAT  CONDYLOMATA  (Figs.  261,  262)  constitute  the  characteristic  vulvar 
lesions  of  secondary  syphilis.  If  the  overlying  epithelial  layers  are  thrown  ofT, 
the  flat  condyloma  becomes  a  superficial  ulcer,  as  mentioned  under  syphilis. 

Treatment.  The  common  wart  needs  no  treatment  unless  large  or  in  some  way 
troublesome.  In  such  a  case  it  may  be  removed  the  same  as  warts  elsewhere,  viz. : 
by  injecting  a  few  drops  of  cocaine  solution  beneath  it  and  then  snipping  it  off  with 
the  scissors.  The  base  should  be  touched  with  carbolic  acid  or  other  cauterant, 
to  check  the  bleeding  and  prevent  return  of  the  wart.  If  the  bleeding  is  free,  it 
may  be  checked  with  one  or  two  sutures.  If  the  patient  objects  to  this  excision  of 
the  wart,  the  cannabis  Indica  and  salicylic  acid  mixture  (see  Formulae)  may  be 
applied.  This  is  to  be  painted  over  the  wart  with  a  camels-hair  brush.  It  should 
be  applied  freely  morning  and  evening,  the  hard  crust  over  the  top  of  the  gi'owth 
being  occasionally  removed,  that  the  medicine  may  penetrate  deeper.  This  treat- 
ment continued  for  a  week  or  two  will  often  cause  the  wart  to  disappear,  but  it  does 
not  always  do  so.  This  treatment  is  rather  tedious  and  uncertain,  but  it  is  not 
painful  and  patients  frequently  prefer  it. 

The  pointed  condylomata  are  treated  as  follows: 

1.  Stop  the  irritating  discharge  which  causes  the  condylomata.  This  requires 
an  antiseptic  vaginal  douche,  once,  twice  or  thrice  daily,  depending  on  the  amount 
of  discharge.  The  douche  removes  the  discharge  from  the  vagina  and  prevents  it 
irritating  the  structures  around  the  vaginal  entrance.  In  addition  to  the  douche, 
the  patient  mil  probably  require  special  treatment  as  indicated  by  the  nature  of  the 
disease  giving  rise  to  the  discharge. 

2.  Keep  the  condylomata  clean  and  dry.  This  is  accomplished  by  washing 
several  times  daily  mth  an  antiseptic  solution,  for  example,  bichloride  (1  to  2000) 
and  then  drying  with  absorbent  cotton  pnd  dusting  freely  with  some  drying  powder 
such  as  calomel  or  equal  parts  of  bismuth  Sub.-itiate  and  prepared  chalk  or  rqual 
parts  of  salicylic  acid  and  calomel.  T^^^  ^^wder  composed  of  tannic  acid,  bori  cid 
and  xeroform  (see  Formulae)  does  well,  as  does  v<;:so  the  resorcin  powder  (sec  or- 
mulse).  The  patient  is  given  a  prescription  for  the  required  powder  and  dii  Led 
to  dust  it  on  freely  several  times  daily.  In  the  office  treatment,  silver  nitrate  stick 
or  a  strong  solution  may  be  applied  as  a  cauterant,  or  carbolic  acid  may  be  used 
as  a  cauterant,  after  anesthetizing  the  growth  by  the  application  of  cocaine  solution 


446  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

(20%).  Another  excellent  cauterant  application  is  pure  formol,  applied  after  the 
use  of  a  cocaine  solution  to  prevent  pain. 

3.  Excision.  This  is  the  best  plan  to  adopt  when  there  are  only  a  few  separate 
condylomata.  The  growths  are  snipped  off  with  the  scissors  and  the  base  of  each 
touched  with  carbolic  acid  or  liquor  ferri  subsulphatis  to  stop  the  bleeding.  If  the 
base  is  wide  and  considerable  pain  is  anticipated,  a  few  drops  of  cocaine  solution 
(y  %)  may  be  injected  under  the  growths  before  excision.  If  there  is  free  bleeding 
the  little  wound  may  be  closed  with  a  suture.  When  a  large  mass  has  formed 
(Fig.  259)  with  a  broad  and  vascular  base,  perhaps  extending  into  the  vagina,  it  is 
better  to  give  the  patient  a  general  anesthetic  and  remove  the  growth  thoroughly 
with  the  scissors  and  curet. 

In  PREGNANCY  it  is  Well  to  get  along  if  possible  with  local  cleanliness  and  drying 
powders  and  mild  astringents.  Any  operative  measure,  such  as  excision  of  the 
condylomata  or  cauterizing  them,  may  lead  to  miscarriage.  In  many  cases  the 
simple  measures  above  mentioned  will  effect  a  cure.  But  when  the  condylomata 
are  not  cured  by  the  simple  means,  particularly  if  the  growth  is  extensive,  the 
patient  should  be  anesthetized  and  the  mass  entirely  removed.  Though  miscar- 
rige  or  premature  labor  may  result  from  such  treatment,  it  is  not  probable  and  with 
such  a  case  some  risk  must  be  taken.  If  large  condylomata,  that  retain  secretion  in 
the  crevices,  are  allowed  to  remain  until  labor,  they  become  a  source  of  great  danger 
to  the  mother  on  account  of  the  liability  to  puerperal  sepsis.  There  is  danger  to  the 
child  also,  particularly  in  gonorrhoeal  cases,  because  of  the  liability  to  eye-infec- 
tion and  destructive  ophthalmia. 

The  flat  condylomata  require  the  regular  constitutional  treatment  for  secondary 
syphilis.  Locally,  cleanliness  should  be  secured  by  frequent  washing  with  a  car- 
bolic or  other  antiseptic  solution.  If  there  is  much  vaginal  discharge,  antiseptic 
vaginal  douches  should  be  given.  Each  time  the  parts  are  washed,  Jthey  should  be 
dried  thoroughly  with  absorbent  cotton  and  dusted  freely  with  some  drying  powder. 
Calomel  makes  an  effective  drying  powder  in  these  cases. 

If  there  is  troublesome  itching  or  smarting,  the  lesions  may  be  touched  occa- 
sionally with  silver  nitrate  solution  (10%).  If  an  ulcer  forms  it  requires  the  treat- 
ment for  ulcer,  given  elsewhere. 

CYSTS  OF  VULVA. 

Occasionally  sebaceous  cysts  occur  on  the  labia  majora  or  the  mons  veneris. 
They  present  the  same  characteristics  and  require  the  same  treatment  as  sebaceous 
cysts  elsewhere.  Figs.  278  and  279  show  large  labial  cysts.  Cysts  of  the  vulvo- 
vaginal gland  have  already  ])een  considered. 

Several  cysts  of  the  la])ia  minora  have  been  reported  (Fig.  277).  It  is  generallly 
supposed  that  they  arise  from  embryologically  misplaced  glandular  rests.  If  large 
enough  to  be  troublesome  they  are  to  be  excised.  Fig.  280  shows  a  cyst  of  the 
clitoris. 

CYSTS  OF  VAGINA. 

Vaginal  cysts  are  7-are  and  their  origin  is  not  certain.  Some  are  supposed  to 
arise  from  the  remains  of  the  duct  of  Gartner,  but  others  are  found  in  other  situa- 


CYSTS  OF  THE  VAGINAL  WALL  447 

tions.  Vaginal  cysts  vary  in  size  from  the  end  of  the  finger  to  as  large  as  the  fist 
and  even  larger  (Figs.  305,  306).  In  some  cases  the  vaginal  wall  is  separate  from 
the  cyst  and  moves  freely  over  it,  while  in  other  cases  the  vaginal  wall  is  closely 
adherent  to  the  cyst,  apparently  forming  part  of  it. 

The  contents  of  the  cyst  may  be  lii<:e  serum  or  may  he  milky  or  may  be  dark  and 
thick,  the  color  and  consistency  depending  on  the  amount  of  hemorrhage  into  the 
cyst  cavity. 

Diagnosis.  The  cyst  differs  from  vaginal  hernia  in  that  it  is  of  gradual 
development  and  without  apparent  cause,  gives,  on  coughing,  no  impulse  separate 
from  the  adjacent  vaginal  wall,  can  not  be  reduced  and  is  not  associated  with 
intestinal  disturbance.  The  cyst  differs  from  vaginal  abscess  in  that  inflamma- 
tory symptoms  are  absent.  In  some  cases,  infection  of  the  cyst  contents  takes 
place  and  the  cyst  becomes  an  abscess.  In  such  cases  it  is  distinguished  from  a 
simple  abscess  b}^  the  presence  of  a  swelling  long  before  the  inflammatory  S3^mp- 
toms  developed.  In  some  cases  a  swelling  that  appears  to  be  a  vaginal  cyst  is 
simply  a  pocket  from  the  urethra  (suburethral  abscess).  Before  subjecting  a 
patient  to  operation,  it  is  well  in  a  doubtful  case,  to  draw  off  a  small  quantity  of 
fluid  from  the  supposed  cyst  with  an  aspirator  that  the  diagnosis  may  be  confirmed. 

Two  other  conditions  that  should  receive  attention  in  the  differential  diagnosis  of 
vaginal  cyst  are,  double  vagina  and  double  ureter.  In  a  case  of  double  vagina 
the  second  vagina  may  be  completely  shut  off  and  filled  with  old  menstrual  blood. 
It  would  usually  be  somewhat  larger  and  less  tense  than  the  ordinary  vaginal  cyst, 
though  the  latter  are  frequently  of  considerable  size.  There  would  be  double  uterus 
and  the  relation  of  the  mass  to  the  uterus  would  point  to  one-sided  hemato-colpos. 
From  HYDRO-URETER  Or  a  supernumerary  ureter,  the  differentiation  would  also  be 
rather  difficult  and  depend  principally  on  the  shape  and  tension  of  the  swelling. 
In  a  case  of  double  ureter,  if  one  ended  blindly  along  side  the  vagina  and  became 
distended  with  urine  it  would  form  a  mass  which  would  be  more  sausage-shaped 
and  have  less  tension  than  a  vaginal  cyst.  A  puncture  of  the  mass  with  an  aspira- 
ting needle,  of  course,  aids  greatly  in  differentiating  between  these  conditions — 
the  presence  of  blood  speaking  for  hemato-colpos,  and  of  urine  for  hydro-ureter. 

Hernia  must  be  carefully  excluded  before  aspirating,  or  fatal  peritonitis  may 
result.  If  it  is  intended  to  remove  the  cyst  by  operation,  only  a  small  amount  of 
fluid  should  be  removed  for  diagnostic  purposes,  for  the  extirpation  is  more  easily 
carried  out  when  the  cyst  is  distended  than  when  collapsed. 

Treatment.  If  the  cyst  is  large  and  troublesome,  the  most  satisfactory  way  of 
dealing  with  it  is  by  extirpation,  provided  it  is  situated  in  the  lower  part  of  the 
vagina  where  complete  extirpation  is  practicable.  If  it  is  so  situated  that  it  can 
not  be  completely  extirpated,  remove  a  large  part  of  the  wall,  curet  the  remaining 
portion  and  pack  with  gauze,  and  treat  as  an  abscess  cavity.  If  the  patient  is 
averse  to  operation,  the  cyst  may  be  simply  emptied  by  aspiration.  There  is  a 
possibility  that  it  will  remain  collapsed  for  sometime  or  even  permanently.  How- 
ever, the  probability  is  that  it  will  refill  in  a  short  time  and  that  extirpation  will  be 
necessary. 

If  the  cyst  is  first  discovered  during  pregnancy,  do  not  disturb  it  until  labor  begins. 
When  labor  comes  on  and  the  child's  head  is  beginning  to  press  into  the  pelvis, 


448  DISEASES  OF  EXTERNAL  GENITALS  A\D  VAGI.N'A 

smpty  the  cyst  with  an  aspirator,  to  give  room  for  the  passage  of  the  child.  Do 
not  attempt  extirpation  of  the  cyst  nor  incision  and  drainage,  until  the  patient  has 
recovered  from  parturition. 

NON=MALIQNANT  TUMORS  OF  VULVA. 

Fibrous  tumors  (fibromata)  may  occur  in  the  connective  tissue  of  the  vulva. 
They  are  rare.  When  present  they  usually  involve  one  of  the  labia  majora  (Figs. 
275,276). 

In  some  tumors  there  are  also  bundles  of  muscular  tissue,  evidently  derived  from 
the  muscle  fibers  of  the  round  ligament  or  of  the  skin.  Such  tumors  are  of  course 
fibro-myomata.  Other  tumors  have  a  preponderance  of  fat  (lipomata),  the  con- 
nective tissue  simply  forming  trabeculae  between  the  fat  lobules.  Still  other 
tumors  contain  myxomatous  tissue,  giving  the  myxo-fibromat a  and  the  nwxo-lipo- 
mata.  A  very  rare  form  of  tumor  in  this  region  is  the  chondroma.  A  few  ca.ses  of 
chondroma  of  the  clitoris  have  been  reported,  in  at  least  one  of  which  considerable 
ossification  had  taken  place. 

These  non-mahgnant  tumors  of  the  vulva  may  vary  in  size  from  an  acorn  to  a 
child's  head.  They  present,  in  this  locality,  the  same  symptoms  and  signs  that 
cha,racterize  them  elsewhere.  The  patient  complains  principally  of  the  weight  of 
the  gi-owth  and  of  its  being  in  the  way.  When  large,  they  become  pedunculated. 
On  account  of  the  friction  the  surface  may  become  abraided  and  infected  and 
ulcerated,  adding  greatly  to  the  patient's  distress.  The  treatment  for  these 
growths  is  excision. 

NON=MALIQNANT  TUMOR  OF  VAGINA. 

Solid  tumors  (fibrous  and  myomatous)  occasionally  develop  in  the  vaginal  wall. 
Such  a  tumor  may  be  mistaken  for  a  hernia  or  a  cyst  or  a  malignant  tumor.  Solid 
tumors  in  this  situation  are  so  rare  as  to  require  no  detailed  consideration,  but  this 
po.s.sibility  of  their  existence  must  be  kept  in  mind  when  endeavoring  to  determine 
the  character  of  a  swelling  in  this  region. 

When  large  enough  to  cause  trouble,  they  require  the  same  treatment  as  vaginal 
cysts,  i.  e.  extirpation. 

STASIS  HYPERTROPHY  OF  VULVA. 

Stasis  hypertrophy  of  the  external  genitals  is  a  chronic  enlargement  of  the  same> 
due  principally  to  interference  with  the  lymph  circulation.  "Elephantiasis"  is 
the  term  under  which  most  authors  describe  this  condition,  but  the  inport  given  to 
this  word  varies  so  much  that  its  use  leads  to  confusion.  It  has  been  applied  on  the 
one  hand  indiscriminately  to  nearly  all  chronic  enlargements  of  the  labia  and,  on 
the  other  hand,  as  a  special  term  for  the  designation  of  the  swelling  due  to  the  local 
invasion  of  the  lymph  channels  by  a  parasite  (filaria  sanguinis  hominis).  To  pre- 
vent this  confu.sion  I  think  best  to  adopt  another  term,  one  about  which  there  can 
be  no  misunderstanding  and  which  indicates  the  most  important  factor  in  the 
evolution  of  the  clinical  picture.     The  essential  lesion  is  a  stasis  hypertrophy,  what- 


STASIS  OF  HYPERTROPHY  OF  VULVA  449 

ever  the  cause  of  the  stasis  may  be.  As  explained  below  under  etiology,  the  stasis 
maybe  due  to  persistent  ulceration  with  resulting  scar  tissue,  or  to  an  obstructive  dis- 
turbance in  the  inguinal  lymph  glands  or  to  local  invasion  of  lymphatics  by  a  parasite 
(hlaria).  The  term  "ulcus  rodens"  given  to  the  condition  by  some  writers,  is  very 
good  for  designating  that  peculiarly  persistent  form  of  ulceration  which  is  a  promi- 
nent feature  in  many  of  these  cases,  but  as  a  term  for  the  whole  clinical  picture  it 
is  not  appropriate.  The  hypertrophy  may  be  present  without  ulceration  and,  on 
tiie  other  hand,  a  rodent  ulcer  may  be  present  without  particular  hypertrophy. 
Stasis  hypertrophy  does  not  include  the  following  forms  of  vulvar  enlargement: — 

a.  Malformations,  nor  the  condition  known  as  "  congenital  elephantiasis,"  which 
is  in  reality  a  kind  of  soft  fil)roma. 

b.  The  slight  enlargement  of  one  or  both  labia  minora,  without  lymph  obstruc- 
tion and  which  is  supposed  to  be  due  to  frequent  irritation  of  the  structures. 

c.  The  enormous  enlargement  of  the  labia  minora  seen  in  some  barbarous  tribes, 
particularly  the  Hottentots  (Fig.  268).  This  is  due  not  to  lymph  stasis  but  to  cer- 
tain manipulations  practised  on  the  female  children,  particularly  stretching  of  the 
parts  manually  or  by  weights. 

d.  Fibroma,  lipoma,  hematoma,  carcinoma,  sarcoma,  ordinary  edema,  acute 
inflammatory  enlargement,  hernia. 

e.  The  slighter  degress  of  enlargement  found  in  the  various  forms  of  vulvar 
ulceration,  namely,  in  the  syphilitic,  tubercular,  malignant  and  rodent  ulcers. 
In  each  of  these  conditions,  when  present  for  some  time,  there  is  usually  slight 
stasis  hypertrophy,  but  the  disease  giving  rise  to  the  ulceration  is  the  important 
feature  and  hence  the  case  should  be  classed  under  syphilis  or  tuberculosis  or  ma- 
lignant disease  or  rodent  ulcer.  However,  with  syphilis  or  rodent  ulcer,  as  the  case 
continues  the  hypertrophy  may  in  time  become  the  most  important  feature  and 
then  the  case  could  properly  be  classed  as  one  of  stasis  hypertrophy.  If  this  fact 
of  the  possible  overlapping  of  these  terms  were  kept  in  mind  and  yet  a  definite 
meaning  were  attached  to  each  term  when  used,  much  confusion  would  be  avoided. 
I  think  the  term  "elephantiasis"  should  be  reserved  for  those  cases  of  vulvar  en- 
largement in  which  the  enlargement  becomes  very  gi-eat,  i.  e.  of  really  elephantine 
proportions  (Fig.  255). 

Etiology.     There  are  supposed  to  be  three  causative  factors: 

1.  Chronic  ulceration  about  the  vulva.  This  has  long  been  recognized  as  an 
etiological  factor  in  the  majority  of  cases.  In  most  cases,  the  ulceration  spreads  at 
one  point  and  heals  at  another,  forming  scar  tissue.  The  contraction  of  the  scar 
tissue,  and  of  the  inflammatory  infiltration  under  the  ulcer,  obstructs  the  circulation, 
particularly  of  the  lymph,  and  causes  stasis,  chronic  irritation,  infiltration  and 
hypertrophy  of  the  tributary  structures.  This  same  ulceration  may  lead  to  infec- 
tion of  the  lymph  glands  and  the  obstructive  condition  mentioned  in  the  next  para- 
graph.    In  Fig.  254,  the  masses  are  raised  to  show  the  ulceration  beneath. 

2.  Obstructive  changes  in  the  inguinal  lymphatic  glands.  This  factor  was  brought 
out  by  F.  Koch,  and  helps  to  account  for  those  cases  in  which  there  has  been  no 
extensive  ulceration.  The  obstruction  of  the  lymph  glands  by  disease  of  these 
structures  may  be  an  important  factor  also  in  those  cases  accompanied  by,  and 
apparently  due  to,    chronic  ulceration.     The    closing  of    these  lymph  highways 


450  DISllASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

through  the  glands  may  be  brought  about  by  extirpation  of  the  glands  or  by 
suppuration  of  the  same,  or  even  by  inflammatory  or  degenerative  processes  that 
stop  short  of  suppuration,  such,  for  example,  as  tertiary  syphilis. 

3.  Local  invasion  of  the  vulvar  lymphatics  by  the  filaria  sanguinis  hominis. 
This  is  rare  or  unknown  in  this  country,  but  it  occurs  as  an  endemic  affection  in 
some  countries  (India,  Barbadoes  and  the  Antilles).  Mosquitoes  are  supposed  to 
deposit  the  embryo  beneath  the  epidermis.  There  the  parasite  multiplies  to  such 
an  extent  as  to  choke  the  lymph  channels,  the  obstruction  being  due  to  both  the 
parasites   proper   and   the   ova. 

Stasis  hypertrophy  is  a  rather  common  affection  among  prostitutes,  in  whom  the 
constant  irritation  from  frequent  coitus  and  from  various  infections  and  from  lack 
of' cleanliness,  tends  to  keep  up  indefinitely  the  chronic  ulceration,  which  usually 
precedes  and  accompanies  the  hypertrophy.  In  this  class,  chronic  ulceration  is 
favored  also  by  the  depressed  general  health  and  in  many  cases  by  tertiary  syphilis 
or  the  post-syphilitic  state.  The  post-syphilitic  state  probably  predisposes  to 
stasis  hypertrophy  by  producing  poor  tissue  resistance  which  favors  chronic  ulcera- 
tion, and  also  by  producing  a  change  in  the  local  lymph  glands  which  interferes 
more  or  less  with  the  flow  of  lymph  through  them. 

Pathology  and  Symptoms.  There  is  marked  hyperplasia  of  the  skin  and  sub- 
cutaneous tissues,  and  the  lymph  spaces  are  dilated.  There  is  usually  considerable 
round-cell  infiltration  and  connective  tissue  proliferation.  In  some  cases  there  is 
infection  of  the  lymph  spaces  and  the  formation  of  pockets  of  pus,  but  this  is  not  a 
part  of  the  essential  pathology  of  the  disease.  In  the  absence  of  infection,  there  are 
no   evidences  of  acute  inflammation  in  ordinary  stasis  hypertrophy. 

The  enlarged  structures  have  about  the  normal  color.  The  skin  may  be  smooth 
(glabrous  variety)  or  rough  and  warty  (verrucous  variety)  v/ith  marked  exaggera- 
tion of  the  normal  skin  folds.  The  process  may  effect  the  clitoris  alone  or  one  of  the 
labia  alone  or  it  may  affect  all  of  these  structures  simultaneously  or  in  succession. 

There  is  usually  present  more  or  less  chronic  ulceration.  In  that  variety  due  to 
the  filaria,  the  parasite  and  ova  are  found  choking  the  lymph  spaces  and  there  are 
also  evidences  of  acute  inflammatory  reaction.  The  enlargement  in  stasis  hyper- 
may  vary  in  size  from  a  small  thickening,  hardly  noticeable,  to  a  mass  so  large  as 
to  prevent  coitus  and  interfere  with  walking  (Figs.  249  to  253) 

Examination  reveals  the  enlargement  and  usually  also  the  ulceration  and  scar 
tissue.  In  the  absence  of  infection,  there  are  no  acute  inflammatory  symptoms 
and  usually  but  little  congestion. 

The  patients  complain  of  some  discharge  and  itching  about  the  genitalia  and  not 
infrequently  symptoms  of  irritation  on  the  part  of  the  bladder  and  rectum.  What 
usually  brings  the  patient  to  the  physician  is  the  discharge  and  enlargement,  with 
resulting  discomfort  and  inconvenience  in  walking  and  difficulty  in  coitus. 

Diagnosis.  Tertiary  syphilitic  lesions  of  the  vulva  not  infrequently  resemble 
the  affection  under  consideration,  there  being  present  syphilitic  ulceration  and 
syphilitic  deposit  in  the  tissue.  For  this  reason  a  thorough  course  of  iodides  is 
advisable  in  nearly  all  these  cases  as  a  diagnostic  measure.  In  some  supposed  cases 
of  simple  stasis  hypertrophy,  when  the  patient  is  put  on  anti-syphilitic  treatment 
the  ulcers  heal  rapidly  and  the  swelling  rapidly  disappears,  showing  that  the  trouble 


TREATMENT  OF  STASIS  HYPERTROPHY 


451 


was  syphilis  and  not  ordinary  stasis  hypertrophy.  However,  the  post-syphihtic 
state  undoubtedly  predisposes  to  chronic  ulceration  with  resulting  stasis  hyper- 
trophy, and  a  large  numl^er  of  the  persons  so  afflicted  are  old  syphilitics.  That  it  is 
not  syphilis  in  the  active  stage,  is  shown  by  the  therapeutic  test — the  iodides 
rarely  doing  much  good. 

From  stasis  hypertrophy  we  must  distinguish  also  tuberculosis  of  the  vulva 
and  malignant  disease,  ))y  the  special  diagnostic  points  given  under  each.  To  be 
distinguished  also  are  fil)r<)ma,  li})()ma,  hernia  and  the  enlargement  of  the  labia 
minora  previously  mentioned. 

Tn  that  rare  form  of  stasis  hypertrophy  due  to  the  filaria,  considerable  acute 
inflammatory  reaction  follows  the  invasion  of   the  lymph  spaces  by  the   parasite 


A.  c. 

Fig.  485.  Excision  of  External  Genitals.  A.  Showing  enlarged  labia  ("stasis  hyper- 
trophy;, with  the  incision  made  on  the  left  side.  B.  Showing  the  wound  left  when  the 
diseased  structures  are  removed.  The  bleeding  vessels  are  tied  and  the  suturing  is  begun. 
(Hirst— diseases  of  Women.) 


and  at  this  stage  it  is  very  liable  to  be  mistaken  for  erysipelas  or  ordinary  cellu^ 
litis.  After  these  acute  symptoms  subside  the  brawny  induraton  remains.  Acute 
exacerbations  occur  at  irregular  intervals  and  with  each  exacerbation  there  is  a 
decided  increase  in  the  hypertrophy.  If  pus  infection  of  the  dilated  lymph  spaces 
takes  place,  abscesses  and  sinuses  form. 

Treatment.  The  treatment  of  stasis  hypertrophy  is  naturally  divided  into  two 
parts — that  for  the  ulceration  and  skin  irritation,  and  that  for  the  swollen  structures. 

The  first  consists  in  cleanliness  and  the  employment  of  the  measures  mentioned 
under  ulcer  and  under  vulvitis. 

The  second,  i.  e.  treatment  for  the  large  masses,  is  excision.  In  some  of  the  milder 
cases  the  removal  of  the  irritation  and  dermatitis  and  the  treatment  of  the  ulcera- 


452  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

tion,  will  do  away  with  part  of  the  swelling  (the  coincident  edema)  and  relieve  the 
patient  so  much  that  she  is  comfortable.  In  most  cases,  however,  particularly 
where  the  enlargement  is  marked,  the  masses  should  be  removed.  In  some  cases 
the  masses  are  so  much  in  the  way  that  they  must  be  removed  before  the  ulceration 
can  be  satisfactorily  treated.  But  on  account  of  the  danger  of  infection  the  ulcera- 
tion should  be  healed  as  far  as  possible  and  all  the  dermatitis  removed  before  ex- 
cision of  the  mass.  Infection  is  particularly  dangerous  in  these  cases  on  account 
of  the  gi-eat  dilatation  of  the  lymph  spaces,  and  strict  antiseptic  care  must  be  em- 
ployed in  handling  them. 

The  l^est  wav  to  remove  such  a  mass  is  by  clean  excision  with  the  knife  or  scissors 
and  closure  of  the  resulting  wound  with  sutures  (Fig.  485) .  Bleeding  is  free  and 
many  artery  forceps  are  needed  to  catch  the  small  vessels.  When  there  is  a  large 
mass  with  a  broad  pedicle,  it  is  best  to  close  the  wound  immediately,  a  little  at  a 
time  as  the  incision  is  extended  and  the  mass  gradually  excised.  In  this  way  the 
sutures  stop  the  bleeding  at  once,  no  ligatures  are  necessary  and  comparatively 
little  blood  is  lost. 

The  older  method  of  removal  with  the  cautery  leaves  a  broad  surface  to  heal  by 
gi-anulation  and  there  is  much  resulting  scar  tissue  and  distortion.  Except  in  the 
cases  of  very  small  pedicle,  it  is  inferior  to  excision  with  the  knife.  The  knife- 
excision  leaves  the  edges  of  the  wound  in  condition  for  a?ccurate  approximation 
and  rapid  union  wdth  a  minimum  amount  of  scar  tissue. 

PUDENDAL  HERNIA. 

A  pudendal  hernia  is  a  protrusion  of  the  intestine  or  omentum  or  other  intra- 
abdominal structure  into  the  external  genitals.  It  may  take  place  by  way  of  the 
inguinal  canal,  in  which  case  the  hernia  is  designated  as  " inguino-labial "  or  ''su- 
perior labial." 

The  protrusion  may  take  place  by  way  of  the  vagina,  in  which  case  the  hernia 
is  designated  as  "vaginal,"  " vagino-labial"  or  "inferior  labial." 

Inguino=labial  hernia.  The  round  ligament  ends  in  the  tissues  at  the  top  of  the 
labium  majus.  In  the  fetus,  the  ligament  is  accompanied  along  the  inguinal  canal 
by  a  prolongation  of  the  peritoneum,  forming  a  small  cavity.  This  is  usually  ob- 
literated in  the  full  term  fetus.  In  some  cases,  however,  it  is  not  obliterated 
but  remains  open,  forming  a  small  pocket  or  "canal  of  Nuck,"  and  along 
this  canal  an  inguinal  hernia  may  take  place.  The  hernia  may  advance  no  further 
than  the  inguinal  ring  or,  on  the  other  hand,  it  may  protrude  more  and  more, 
involving  the  upper  part  of  the  labium  majus  and  later  the  whole  labium  (Fig.  281). 
It  corresponds  to  scrotal  hernia  in  the  male  and  presents  practically  the  same  path- 
ology and  symptoms.  In  some  cases  other  structures  than  the  intestine  or  omentum 
have  been  found  in  such  a  hernia-sac,  for  example,  the  ovary,  Fallopian  tube, 
uterus  anrl  even  the  pregnant  uterus. 

VaKino=labial  hernia.  In  rare  cases  a  hernial  protrusion  may  take  place  through 
the  pelvic  outlet  by  way  of  the  vagina.  In  such  a  case  the  hernia  may  descend  in 
front  of  the  broad  ligament,  between  the  uterus  and  the  bladder  or,  more  rarely, 
behind  the  broad  ligament  between  the  uterus  and  the    rectum.     In  either  case 


'  '  PUDENDAL  HERNIA  453 

the  hernial  tumor  appears  first  in  the  vagina  and,  as  it  grows  larger,  approaches  the 
vaginal  opening  anil  distends  the  lower  part  of  one  labium  (Fig.  282).  In  this 
situation  it  produces  an  appearance  somewhat  resembling  a  vulvo-vaginal  cyst, 
for  which  it  may  l^c  mistaken. 

Diagnosis.  Hernia  differs  from  other  swellings  in  this  region,  for  example, 
hematoma,  cyst,  fibroma,  stasis  hypertrophy,  cellulitis,  in  the  following  par- 
ticulars: 

Impulse  on  Coughing.  This  sign,  however,  may  be  absent  if  strangulation 
has  taken  place. 

Resonance  on  Percussion.  This  sign  is  present  only  if  the  mass  contains  in- 
testine.    It  is  not  found  with  omentum  or  ovary  or  tube. 

May  be  reduced  into  abdominal  cavity.  This,  of  course,  is  possible  onh'  in 
reducible  hernia.  If  the  supposed  hernia  cannot  be  reduced  with  the  patient  in  the 
dorsal  position,  she  may  be  placed  in  the  knee-chest  posture  and  the  reduction 
again  attempted.     This  is  especially  effective  in  the  vaginal  form  of  hernia. 

Intestinal  Obstruction.  Usually  there  is  not  enough  obstruction  to  produce 
serious  symptoms  nor  interfere  with  the  passage  of  the  intestinal  contents,  but  when 
evidence  of  such  obstruction  does  occur  it  is  a  very  important  diagnostic  symptom. 

History.  Hernia  usually  appears  in  conjunction  with  some  straining  effort. 
Hematoma  of  the  vulva  is  usually  due  to  some  external  injury.  Cellulitis  follows  a 
wound  or  ulcer.  Stasis  hypertrophy  is  preceded  by  chronic  ulceration  and  scar 
tissue  formation.  The  other  swellings  of  this  locality  (cyst,  tumor)  develop 
gradually  and  without  apparent  cause. 

Treatment.  The  treatment  for  hernia  in  this  situation  is  the  same  as  for  hernia 
elsewhere,  namely,  reduction  and  retention  of  the  replaced  viscera  within  the  ab- 
dominal cavity,  if  that  can  be  satisfactorily  accomplished.  An  inguino-labial 
hernia  can  frequently  be  retained  with  the  ordinary  hernia  truss.  If  the  reduction 
can  not  be  accomplished  or  if  satisfactory  retention  can  not  be  secured,  then  the 
operation  for  the  radical  cure  of  the  hernia  is  indicated. 

In  the  form  of  pudendal  hernia  in  which  the  protrusion  takes  place  by  way  of  the 
pelvic  outlet  and  vagina  (vagino-labial),  there  is  seldom  enough  obstruction  at 
the  hernial  opening  to  produce  troublesome  symptoms.  When  the  patient  is  placed 
in  the  knee-chest  posture,  the  protruding  mass  returns  within  the  abdominal  cavity 
and  in  some  cases  satisfactory  retention  may  be  secured  by  means  of  a  pessary  that 
puts  the  vaginal  walls  on  the  stretch  or  that  plugs  the  vaginal  canal,  ^^arious  forms 
of  pessary  may  be  tried  until  an  effective  one  for  that  particular  case  is  found. 
In  some  cases  the  uterine  supporter,  consisting  of  an  abdominal  belt  and  vaginal 
stem  supporting  a  hard  rubber  cup  or  ball  (Fig.  462),  is  the  most  satisfactory  form 
for  the  vaginal  hernia. 

Where  only  temporary  retention  is  needed,  as  at  the  beginning  of  labor,  the  vagina 
may  be  packed  with  gauze  or  cotton  and  the  patient  kept  in  bed  and  if  necessary 
in  Sim's  posture,  or  in  the  dorsal  posture  with  hip  elevated  on  pillows.  If  the  hernia 
still  persists  in  coming  down,  the  patient  may  be  propped  up  for  a  time  in  a  modified 
knee-chest  posture,  care  being  taken  that  the  abdomen  is  free  from  constriction  or 
pressure,  so  that  the  intestines  may  fall  to  the  upper  part  of  the  abdominal  cavity 
A  vaginal  hernia  associated  with  pregnancy  and  labor  makes  a  serious  complication 


454  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

and  requires  careful  handling,  for  there  is  always  the  danger  that  the  hernia  may 
be  caught  and  held  in  front  of  the  advancing  head,  with  fatal  results. 

A  vaginal  hernia  causing  serious  symptoms,  which  canot  be  relieved  by  other 
measures,  requires  operation  for  the  permanent  closing  of  the  hernial  opening.  In 
a  case  in  which  the  hernial  opening  can  be  satisfactorily  reached  for  operative 
closures  by  way  of  the  vagina,  that  route  for  the  operation  should  be  chosen  as  it 
is  less  dangerous. 
In  other  cases  abdominal  section  is  indicated. 

PUDENDAL  HYDROCELE. 

In  some  patients,  a  canal  persists  along  the  round  ligament,  the  internal  end  of 
the  canal  being  closed.  If  a  collection  of  fluid  takes  place  in  the  sac  thus  formed, 
the  result  is  a  pudendal  hydrocele,  corresponding  to  hydrocele  of  the  cord  in  the 
male.  It  is  called  also  "labial  hydrocele"  and  occupies  the  same  location  as  an 
inguinal  hernia. 

It  differs  from  hernia  in  that  it  is  dull  on  percussion,  can  not  be  reduced,  gives 
little  or  no  impulse  on  coughing,  is  not  associated  with  evidences  of  intestinal  ob- 
struction and  has  developed  gradually  without  apparent  cause.  Great  care  is  neces- 
sary in  diagnosticating  this  rare  affection,  for  it  would  be  fatal  to  mistake  hernia 
for  hydrocele  and  treat  it  by  injection.  It  must  be  differentiated  also  from  cystic 
adeno-myoma  of  the  round  ligament.  Several  such  cases  have  been  reported. 
In  hydrocele,  the  cyst  wall  would  be  thinner  than  in  the  cystic  adeno-myoma, 
though  in  some  of  the  cases  the  adeno-myoma  can  only  be  distinguished  micro- 
scopically. Pudendal  hydrocele  must  be  differentiated  also  from  hernia  of  the 
ovary  with  cystic  degeneration. 

Treatment.  If  the  collection  of  fluid  is  small  and  causes  no  inconvenience,  leave 
it  alone  or  have  the  patient  rub  in  some  ointment,  such  as  oleate  of  mercury,  once 
daily  with  gentle  massage.  If  the  swelling  causes  trouble,  the  fluid  may  be  drawn 
off  and  an  irritating  injection  made,  the  same  as  for  treatment  of  ordinary  hydrocele 
in  the  male.  Before  employing  this  treatment  it  must  be  determined  positively 
that  the  cavity  of  the  sac  is  shut  off  from  the  peritoneal  cavity. 

A  safer  and  more  certain  plan  of  treatment  is  to  extirpate  the  sac,  or  a  large  part 
of  it,  and  close  the  wound  by  sutures. 

HEMATOMA  OF  VULVA. 

A  hematoma  is  a  collection  of  l)l<)od  in  the  tissues.  The  genitals  are  very  vascu- 
lar and  also  present  much  loose  sulxnitancous  tissue  into  which  hemorrhage  may 
take  place  with  but  little- resistance  until  a  large  mass  is  formed  (Fig.  248). 

Pregnancy,  pelvic  tumors  and  otiicr  conditions  that  increase  the  vascularity  of 
the  parts,  predispose  to  hematoma.  The  exciting  cause  is  an  injury  that  starts 
subcutaneou.'j  bleeding.  A  severe  injury  caused  by  a  fall  astride  some  object  is 
very  liable  to  cause  hematoma.  The  bruising  of  the  tissues  by  the  child's  head  in 
labor  or  by  the  obstetric  forceps  may  cause  hematoma.  A  slight  sulx-utaneous 
surgical  proceedure  about  the  genitals,  such  as  puncture  of  a  cyst  with  a  hypodermic 
needle,  may  be  followed  by  a  hematoma.     For  this  reason  it  is  important  in  Dunc- 


HEMATOMA  OF  VULVA  455 

turing  a  cyst  of  the  vulvo-vaginal  gland  to  make  the  puncture  on  the  inner  side 
where  the  intervening  hiyer  of  tissue  is  thin  and  comparatively  free  from  veins. 
During  pregnancy  the  veins  of  the  external  genitals  Ijecome  enlarged  and  varicose 
and  sometimes  there  is  a  spontaneous  rupture  of  a  vein  subcutaneously,  giving  rise 
to  a  hematoma  without  external  injury. 

Symptoms  and  Diagnosis.  After  some  slight  injury,  a  swelling  is  noticed,  which 
increases  rapidly  in  size  and  is  accompanied  by  considerable  pain,  especially  when 
the  patient  is  standing.  If  large,  the  swelling  distorts  the  parts  very  much,  in 
some  cases  so  much  that  the  individual  structures  are  identified  with  difficulty. 
The  swelling  presents  induration  and,  if  a  large  collection  of  blood  has  formed, 
there  may  be  fluctuation. 

The  swelling  and  pain  and  induration  are  much  the  same  as  in  acute  cellulitis  and 
it  may  be  mistaken  for  that  affection,  particularly  if  the  hemorrhage  is  situated  so 
deeply  that  the  skin  is  not  discolored.  In  one  typical  case,  which  I  saw  in  consul- 
tation, the  physician  was  much  alarmed,  fearing  that  he  had  caused  a  serious 
infection.  He  had  punctured  a  small  cyst  with  a  hypodermic  syringe  and  drawn  off 
the  fluid.  Within  twenty-four  hours  a  large  swelling  gradually  formed  accom- 
panied with  much  pain  and  distending  and  distorting  the  genitals  on  that  side. 
In  the  next  twenty-four  hours  the  sweUing  seemed  to  get  worse  instead  of  better 
He  decided  it  would  be  necessary  to  make  deep  incisions  to  stop  the  serious  and 
spreading  infection.  When  I  saw  the  patient  with  him,  the  examination-findings 
together  with  the  history,  showed  that  the  trouble  was  a  hematoma  following  the 
hypodermic-needle  puncture.  Rest  with  the  hips  elevated  and  an  ice-bag  applied 
locally  was  the  treatment  adopted,  with  satisfactory  result. 

The  differential  diagnostic  points  between  hematoma  and  cellulitis  are  that  the 
hematoma  begins  to  develop,  within  a  few  hours  after  the  injury,  too  soon  for 
infection  to  develop,  and  that  there  is  little  or  no  fever  and  that  the  tender- 
ness on  superficial  palpation  and  the  local  heat  are  neither  so  marked  as  in  acute 
inflammation.  In  a  few  days  the  extravasated  blood  finds  its  way  to  near  the  sur- 
face and  colors  the  skin  and  confirms  the  diagnosis. 

Treatment.  Put  the  patient  to  bed  and  elevate  the  hips  by  placing  a  pillow 
under  them,  at  the  same  time  arranging  a  pillow  under  the  knees  so  that  the  patient 
will  be  comfortable,  and  apply  an  ice-bag  over  the  swelling.  The  patient  should  be 
kept  perfectly  quiet  in  this  position  until  the  hemorrhage  ceases — several  hours  if 
necessary.  If  there  is  much  pain,  sedatives  should  be  given  to  keep  the  patient 
quiet.  The  cessation  of  the  hemorrhage  is  indicated  by  the  swelling  ceasing  to 
increase  in  size  and  by  diminution  in  the  pain. 

If  the  hematoma  is  very  large  and  increasing  in  size,  it  is  advisable  to  incise  the 
swelling,  under  antiseptic  precautions,  turn  out  the  clots,  ligate  the  bleeding  vessel 
or  vessels,  cleanse  the  cavity  and  obliterate  it  with  sutures.  This  avoids  sloughing 
of  the  skin,  suppuration  of  the  blood  collection  and  dangerous  septicemia.  In 
the  later  treatment  of  a  case  in  which  the  incision  has  not  been  necessary,  the 
patient  must  be  kept  in  bed  until  absorption  is  well  under  way.  If  suppuration 
takes  place  in  the  collection  of  blood  the  resulting  abscess  must  be  opened. 

A  large  hematoma,  especially  if  occuring  in  labor  or  advanced  pregnancy,  is  a 
serious  affair.     The  swelling  may  burst  and  fatal  external  hemorrhage  occur  or  the 


456 


DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 


patient  may  bleed  to  death  without  external  opening,  the  blood  simply  burrowing 
in  the  loose  subcutaneous  tissues.  Such  a  serious  result  is  rare,  but  the  fact  that  it 
may  occur  must  be  kept  in  mind  and,  if  the  hemorrhage  persists  in  spite  of  the  ordi- 
nary measures,  the  affection  should  be  treated  by  operation  before  the  patient  is  too 
weak.  After  the  blood-clots  are  turned  out,  an  attempt  should  be  made  to  catch  the 
bleeding  vessels  with  forceps.  If  the  particular  vessel  that  is  bleeding  can  not  be 
made  out,  catch  the  bleeding  tissues  rapidly  with  forceps  until  the  hemorrhage  is 
stopped  and  then  ligate  the  bleeding  areas  en  masse  or  include  them  in  sutures. 

It  has  been  recommended  in  these  cases  to  stop  the  hemorrhage  by  firm  packing, 
but  valuable  time  may  be  lost  in  placing  a  packing  which,  afte,  all,  may  fail  to  stop 
the  bleecUng.  The  safer  plan  in  severe  cases  to  is  catch  the  bleeding  vessels  and 
Ugate  them,  so  that  there  is  no  chance  for  further  loss  of  blood. 

VARICOSE  VEINS  OF  VULVA. 

The  veins  about  the  external  genitals  may  become  markedly  varicose,  the  irregular 
dilatation  being  due  to  some  obstruction  to  the  pelvic  circulation,  such  as  preg- 
nancy or  a  pelvic  tumor.     The  dilatation  of  the  veins  only  rarely  gives  rise  to  trou- 


A. 

Fig.  486.  Excision  of  Varicose  Veins  of  Vulva.  A.  Tne  veins  have  been  exposed 
by  incision  tnrough  the  skin,  and  the  ligatures  are  being  passed.  B.  The  Hgatures 
have  been  tied,  the  varicose  veins  excised  and  the  pedicles  brought  together.  The 
operation  is  completed  by  a  continuous  suture  closing  the  skin-incision.  (Ashton — 
Practice  of  Gynecology.) 

blesome  symptoms.  Sometimes  the  patient  complain,^,  of  itching  or  of  tension  in 
the  parts.  Sometimes  she  becomes  ahinned  on  account  of  the  enlargement  and 
consults  the  physician  simply  to  know  the  cause.  Occasionally,  however,  there 
may  be  marked  enlargement  (Fig.  256)  with  acliinfi;  in  the  i)arts  and  much  irritation 
of  the  skin.  The  dan.<rer  in  these  cases  is  that  a  severe  hemorrhage  may  take  place, 
or  a  large  hematoma  form  from  slight  injury  or  from  spontaneous  rupture  of  a  vari- 
cose vein. 


INJURIES  ABOUT  THE  VULVA  457 

Treatment.  Usuallj'-  no  tveatment  is  required  beyond  directing  the  patient  to 
keep  tiie  i^owels  well  open  and  to  avoid  lifting  or  straining  as  much  as  possible. 
Anything  that  increases  the  intra-pelvic  pressure  or  interferes  with  the  pelvic  circu- 
lation tends  to  increase  the  venous  dilatation.  In  advanced  pregnancy,  an  ab- 
dominal supporter  takes  some  of  the  weight  of  the  uterus  from  the  anterior  part  of 
the  pelvis  and  in  that  way  may  improve  the  circulation  there.  If  the  dilatation  is 
sufficient  to  give  the  patient  trouble,  some  relief  may  be  afforded  l)y  a  pad  and 
T-bantlage,  so  applied  as  to  support  the  veins  and  prevent  further  dilatation.  The 
patient  should  take  the  recumbent  posture  several  times  daily,  and  in  some  cases  it 
may  be  advisable  to  keep  her  in  bed  continuously  in  the  later  weeks  of  pregnancy. 

If  there  should  be  subcutaneous  rupture  of  a  vein,  employ  the  treatment  given 
under  hematoma. 

If  there  should  be  external  rupture,  employ  the  treatment  given  below  for  open 
hemorrhage  following  injury. 

When  in  the  non-pregnant,  the  veins  are  so  much  enlarged  that  they  are  trouble- 
some, they  may  be  excised.  They  are  exposed  by  an  incision  through  skin  covering 
them  (Fig.  486- A),  ligated  at  each  end  and  excised  (Fig.  486-B)  and  the  stumps 
brought  together  and  the  incision  closed  by  sutures. 

INJURIES  OF  EXTERNAL  GENITALS. 

The  genitals  are  in  such  a  well-protected  situation  that  injuries  are  rare.  Such 
injuries  as  do  occur,  apart  from  labor,  are  due  usually  to  a  fall  astride  some  object 
or  to  kicks  and  blows  intentionally  inflicted  or  to  injuries  in  coitus. 

Injuries  in  this  locality  should  be  treated  on  the  same  general  principles  that  gov- 
ern the  treatment  of  injuries  in  other  localities,  viz.,  stop  hemoiThage,  secure  asepsis 
as  far  as  possible,  approximate  divided  tissues  sufficiently  to  restore  function  and 
afterward  protect  the  wound  with  a;  suitable  dressing. 

There  are  two  special  characteristics  of  injuries  in  this  locality  that  must  be  kept 
in  mind. 

1.  Free  hemorrhage.  The  parts  are  very  rich  in  blood  vessels,  particularly  veins, 
and  slight  injury  may  cause  severe  bleeding,  either  as  external  hemon-hage  from  an 
open  wound  or  as  subcutaneous  hemorrhage  from  a  bruise,  giving  rise  to  a 
hematoma. 

An  instance  of  troublesome  hemorrhage  from  a  slight  injury  is  the  persistent 
bleeding  that  occasionally  follows  the  small  tear  of  the  hymen  in  the  first  coitus. 
On  account  of  modesty  and  embarrassment,  the  newly  married  couple  hesitate  to 
call  in  assistance,  and  sometimes  the  bleeding  persists  for  hours — until  they  do 
finally  call  a  physician,  who  may  find  the  bedding  soaked  with  blood  and  the 
bride  almost  exsanguinated. 

Open  hemorrhage  from  injury  to  genitals  should  be  stopped  by  packing  or  by 
sutures  or  by  forceps  or  by  ligature  of  separate  vessels  or  by  ligature  of  the  bleeding 
tissue  en  masse  as  indicated  by  the  nature  of  the  wound.  After  treatment  of  the 
wound,  the  patient  should  be  kept  in  bed  with  hips  elevated  until  all  tendency  to 
hem-orrhage  is  past.  In  attempting  to  stop  hemorrhage,  either  from  a  wound  or 
during  an  operation,  if  the  bleeding  vessels  can  not  be  made  out  and  the  bleeding  is 


$58  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

free,  the  most  satisfactory  plan  is  to  pass  one  or  more  sutures  through  the  bleeding 
area  and  tie  them. 

In  case  of  injury  about  the  venous  masses  called  the  bulbs  of  the  vestibule,  the 
hemorrhage,  whether  open  or  subcutaneous,  may  often  be  controlled  by  packing 
the  vagina  firmly  and  then  puting  a  firm  compress  over  the  vulva,  such  as  a  folded 
towel  held  in  place  by  a  strong  T-bandage  making  firm  pressure. 

In  open  hemorrhage  from  a  small  wound,  if  the  pressure  does  not  control  it,  the 
wound  may  be  packed  with  pledgets  of  cotton  dipped  in  liquor  ferri  subsulphatis 
or  in  tannic  acid  powder,  and  then  the  vaginal  packing  and  vulvar  compress  em- 
ployed. 

In  SUBCUTANEOUS  HEMORRHAGE  (hematoma)  the  patient  should  receive  the 
treatment  described  elsewhere  for  that  affection. 

2.  Marked  swelling.  In  this  locality  the  subcutaneous  tissues  are  loose  and 
decided  swelling  is  liable  to  follow  an  injury,  either  immediately  from  subcutaneous 
hemorrhage  or  serous  effusion  or  later  from  inflammatory  exudate. 

To  prevent  the  swelling,  or  diminish  it  if  present,  put  the  patient  to  bed,  elevate 
the  hips  and  apply  an  ice-bag  over  the  parts.  If  the  swelling  is  from  inflammation, 
hot  applications  may  give  more  relief  than  the  cold. 

For  further  treatment  of  vulvar  swelling  see  hematoma  and  also  cellulitis  of 
vulva. 

KRAUROSIS  VULVAE. 

Kraurosis  vulva  is  a  term  applied  to  a  rather  rare  affection  of  the  external  gen- 
itals characterized  by  atrophy  and  shrinking  of  the  skin  and  obliteration  of  the 
normal  folds,  and  a  change  in  the  consistency  of  the  epidermis  by  which  it  becomes 
somewhat  like  scar-tissue.  It  is  known  also  as  "atrophy  of  the  vulva,"  and  as 
''progressive  cutaneous  atrophy." 

The  essential  cause  is  not  known.  It  has,  in  various  cases,  been  preceded  by 
eczema  and  other  chronic  inflammatory  diseases  of  the  vulva,  by  pruritis  vulvae, 
giving  rise  to  much  scratching  and  irritation  and  excoriation,  by  removal  of  the 
uterine  appendages  and  by  chronic  vaginal  discharge.  It  has,  to  some  extent, 
been  attributed  to  each  of  these  conditions,  but  apparently  none  of  them  constitute 
the  essential  factor  in  its  development. 

Age  seems  to  be  a  definite  factor  in  the  etiology,  for  it  occurs  almost  exclusively 
in  women  near  or  past  the  menopause.  This  would  seem  to  indicate  that  it  is  in 
some  way  connected  with  senile  atrophic  changes.  As  cutaneous  atrophy  is  such  a 
marked  feature  of  the  affection,  it  has  l^een  surmised  that  it  is  due  to  an  atrophic 
affection  of  the  nerves  of  the  parts,  and  marked  changes  in  the  nerves  have  been 
demonstrated.  But  whether  such  changes  are  primary  or  secondary  is  somewhat 
uncertain. 

Pathology  and  Symptoms.  In  the  begiiuung  there  is  a  low-grade  infhunmatory 
process,  which  appears  in  spots  just  outside  the  vaginal  opening  or  on  the  labia. 
The  spots  are  hyperemic  (reddened)  and  may  be  slightly  swollen  but  are  usually 
depressed.  In  the  beginning,  hypertrophic  areas  are  sometimes  noticed.  The 
spots  are  painful  on  pressure  and  for  that  reason  sexual  intercourse,  or  even  the 
introduction  of  a  douche-nozzle,  may  be  very  painful.     As  tlie  disease  progresses, 


KRAUROSIS  VULVAE  459 

the  older  portions  lose  their  color  and  elasticity.  The  hyperemia  disappears  and, 
instead,  the  tissue  becomes  white  and  dry  and  brittle  and  cracks  easily  (Fig.  217). 

Another  marked  characteristic  is  the  tendency  to  shrink.  The  atrophic  contrac- 
tion may  progi-ess  to  such  an  extent  that  the  vaginal  opening  is  much  narrowed 
(Fig.  217).  ^Microscopic  examination  of  the  excised  tissue  shows  that  the  process 
is  essentially  a  chronic  inflammatory  atrophy  or  cirrhosis  of  the  skin.  In  the  new 
areas,  there  is  serous  and  cellular  exudate,  with  hyperaemia  and  occasionally 
slight  hemorrhage.  In  this  stage  there  may  be  decided  thickening  of  the  affected 
spots.  Later,  the  cellular  exudate  becomes  organized,  with  resulting  contraction 
and  hardening  and  atrophy.  The  glandular  structures  (sweat  glands,  sebaceous 
glands  and  hair  follicles)  are  slowly  obliterated  by  pressure-atrophy,  and  there  is 
left  simply  cirrhotic  tissue. 

The  patholgical  changes  just  described  are  usually  accompanied  by  burning 
and  itching  and  tenderness.  Owing  to  the  sensitive  spots  and  the  narrowing  of  the 
vaginal  orifice,  coitus  may  be  painful  or  impossible.  Owing  to  the  brittleness  of 
the  tissues,  the  examination  may  cause  fissures,  which  add  to  the  patient 's  dis- 
comfort. This  affection  is  one  of  the  causes  of  persistent  and  severe  pruritis 
vulvae. 

In  some  cases,  but  little  discomfort  seems  to  result  from  the  pathological  changes, 
The  disease  is  gi-adually  progi*essive  for  a  number  of  years  but  is  not  self-limited 
and  spontaneous  cure  can  not  be  promised,  though  in  the  areas  in  which  the  skin 
structures  are  practically  destroyed,  the  pain  and  itching  may  be  much  diminished. 

Treatment.  Temporary  relief  may  be  afforded  by  the  measures  given  under 
Pruritis  ^'ulvae.  One  case  was  much  benefitted,  in  fact  temporarily  cured,  by  the 
use  of  the  sharp  curette  followed  by  the  long  continued  application  of  a  3%  solution 
of  salicylic  acid  in  alcohol. 

One  Avriter  recommends  that  an  ointment  containing  one  to  three  per  cent,  of 
yellow  oxide  of  mercury,  be  rubbed  well  into  the  parts  by  the  patient  twice  daily, 
and  that  twice  weekly  the  physician  introduce  the  speculum,  cleanse  the  vuh'a  and 
vagina  with  a  spray  of  hydrogen  peroxide  and  then  apply  the  above  ointment  t®  all 
the  affected  surfaces. 

In  these  cases,  the  X-ray  treatment,  by  a  competent  person,  sometimes  gives 
gi'eat  relief  after  other  measures  have  failed,  and  if  continued  may  affect  a  cure. 

Permanent  relief  in  many  cases  may  be  afforded  by  extirpation  of  the  involved 
tissue,  and  this  operation  should  be  carried  out  when  the  symptoms  are  severe  and 
not  relieved  by  other  measures.  Excision  of  the  affected  tissue  should  not,  however, 
be  carried  out  until  the  disease  has  existed  some  time  and  its  probable  limits  can 
be  defined.  If  in  the  early  stage  the  parts  then  affected  are  excised,  there  is 
strong  probaljility  of  the  development  of  the  same  process  in  remaining  tissues, 
necessitating  a  second  operation.  When  an  operation  is  decided  upon,  the  incision 
should  include  all  the  superficial  areas  involved  and  should  be  deep  enough  to 
include  part  of  the  subcutaneous  tissue. 

The  resulting  wound  should  be  closed  as  far  as  possible  by  sutures  (Fig.  485-B). 
When  the  margins  of  the  wound  can  not  be  brought  together,  the  uncovered 
portion,  if  small,  may  be  left  to  gi-anulate.  If  the  uncovered  portion  is  large, 
immediate  skin-grafting  may  be  done  at  the  time  of  the  operation, 


460  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

The  results  of  extirpation  are  encouraging.  Decided  relief  is  afforded  and 
in  some  cases  there  is  a  complete  cure.  Some  of  the  skin  surface,  unaffected  at 
the  time  of  the  operation,  may  show  evidences  of  the  disease  later,  with  symptoms 
requiring  treatment.  If  the  symptoms  are  severe  and  persistent,  those  portions 
of  skin  may  also  be  excised.  This  may  not,  however,  be  necessary  and  other 
methods  for  relieving  the  pruritis  should  be  given  a  thorough  trial. 

PRURITIS  VULVAE. 

Pruritis  vulvae  signifies  simply  itching  about  the  external  genitals,  but  by 
common  usage  the  term  has  come  to  be  restricted  to  those  cases  in  which  the  itch- 
ing and  burning  is  marked  and  persistent. 

Etiology  and  Pathology.  The  general  nervous  disturbances  and  the  local  atrophic 
changes  that  accompany  and  follow  the  menopause,  predispose  to  pruritis  vulvae, 
hence  the  vast  majority  of  cases  are  found  in  that  period  of  life. 

The  following  are  the  exciting  causes: 

1.  Ax  Irritating  Vaginal  Discharge.  The  discharge  may  originate  in  the 
vagina  or  in  the  uterus.  Adhesive  vaginitis,  which  occurs  principally  in  the  aged, 
is  a  frequent  cause  of  pruritis  vulvae.  Sometimes  a  discharge  which  is  so  slight  as 
not  to  be  noticed  by  the  patient,  will  keep  up  a  troublesome  pruritis,  the  pruritis 
disappearing  temporarily  when  the  discharge  is  kept  from  irritating  the  external 
genitals  by  the  administration  of  douches  or  by  a  tampon  against  the  cervix. 

2.  Irritating  urine,  for  example  diabetic  urine,  highly-acid  urine  and  pus- 
bearing  urine  due  to  inflammation  of  the  bladder  or  kidney. 

3.  Parasitic  affections,  of  which  the  most  common  in  this  region  is  pedicu- 
losis pubis.  In  children  thread-worms  from  the  rectum  may  cause  persistent 
itching. 

4.  Skin  diseases,  such  as  eczema,  follicular  inflammation  and  prurigo. 

5.  Lack  of  cleanliness. 

6.  Growth  of  short  bristly  hairs  on  the  inner  surface  of  the  labia.  These 
scratch  and  in-itate  the  adjacent  surfaces  and  sometimes  cause  very  troublesome 
pruritis.  Occasionally  such  irritation  is  caused  by  the  short  hairs  present  for  some 
weeks  after  shaving  the  parts  for  an  operation. 

7.  Friction  from  exercise,  especially  in  very  stout  persons. 

8.  Kraurosis  vulvae,  or  as  it  is  sometimes  called  "local  nerve  fibrosis."  J.  C. 
Webster  carefully  studied  the  microscopic  characteristics  of  excised  tissue  in 
several  cases  of  pruritis  vulvae,  and  found  a  progressive  nerve  fibrosis,  affecting 
principally  the  nerves  of  the  clitoris  and  labia  minora.  It  affected  both  the  nerves 
proper  and  the  nerve  endings.  It  was  apparently  distinct  from  the  cellular  infil- 
tration of  the  subepithelial  tissues  caused  by  scratching. 

9.  Chronic  congestion,  from  diseases  of  the  uterus  or  tubes  or  ovaries  or  other 
pelvic  structures. 

10.  Functional  nervous  disturbance.  In  some  cases,  no  cause  for  the  dis- 
turbance can  be  found  and  apparently  no  local  changes  are  present,  aside  from  the 
abrasions  and  irritation  caused  by  the  scratching.  Under  such  circumstances  the 
disease  is  classed  as  a  "  neurosis." 


PRURITIS  VULVAE  461 

In  some  cases  the  gouty  diathesis  is  apparently  responsible  for  the  trouble. 
The  presence  in  the  blood  of  urea,  sugar,  bile,  or  other  products  of  faulty  metabolism 
have  a  general  irritating  effect  on  the  vulvar  and  vaginal  surfaces.  Alcoholic 
drinks,  rich  foods  and,  in  certain  persons,  fish  or  shell-fish,  may  assist  in  causing 
the  disease. 

Symptoms.  The  patient  complains  of  an  intense  itching  about  the  genitals. 
It  may  be  confined  to  the  clitoris,  labia  or  vestibule,  or  it  may  involve  all  the.se 
structures  and  also  adjacent  regions,  for  example,  the  vagina,  anus  and  inner  sides 
of  the  thighs.  The  itching  and  burning  may  be  practically  continuous,  ])ut  more 
often  it  is  intermittent  in  character.  It  may  disappear  spontaneously  for  several 
hours  or  days  or  even  longer,  only  to  return  as  suddenly  as  it  disappeared.  Con- 
gestion at  the  menstrual  period  or  during  pregnancy  increases  the  pruritis.  Ir.i- 
tating  articles  of  food  and  also  alcoholics  often  have  the  same  effect.  The  warmth 
of  the  bed  usually  makes  the  itching  worse,  consequently  the  patient  may  lose 
much  sleep.  During  sexual  intercourse  the  itching  and  burning  are  much 
increased. 

Frequently  the  distressing  symptoms  persist  in  spite  of  local  and  general  se- 
datives and  in  some  cases  they  become  intolerable,  making  the  patient's  life  a 
burden  to  her.  On  account  of  the  irresistible  tendency  to  scratch  or  rub  the  parts, 
the  skin  becomes  irritated  and  abraded  and  inflamed.  Deep  fissures  may  form 
and  in  some  cases  a  discharging  or  weeping  surface  develops,  to  be  followed  by  scar 
tissue.  The  constant  suffering  makes  the  patient  irritable  and  nervous  and  in 
some  cases  leads  eventually  to  nervous  prostration. 

Treatment.  The  treatment  for  pruritis  vulvae  may  be  presented  in  the  following 
steps : 

1.  Remove  All  Local  Causes  of  Irritation.  These  have  been  enumerated 
under  etiology.  If  an  irritating  vaginal  discharge  is  present  it  must  be  stopped  by 
appropriate  treatment  of  the  disease  causing  it.  If  that  is  not  possible,  the  dis- 
charge may  be  kept  from  irritating  the  genitals  by  washing  it  away  with  antiseptic 
douches.  Sometimes  it  is  advisable,  after  the  douche,  to  introduce  a  tampon 
which  prevents  the  discharge  from  coming  in  contact  with  the  external  genitals. 
The  tampon  is  removed  at  the  next  douche  time.  The  tampon  may  be  used  dry  or 
it  may  be  saturated  with  borax  and  glycerine  (1  to  4)  or  with  acetate  of  lead  and 
glycerine  (1  to  4)  or  with  ichthyol-glycerine  (10%  to  25%).  The  importance  of 
vaginal  discharge  as  a  causative  factor  in  pruritis  is  not  so  gi-eat  as  might  at  first 
be  supposed.  In  fact,  it  is  very  doubtful  if  ordinary  leucorrhoeal  discharge  alone 
ever  causes  severe  pruritis.  In  each  case  there  is  probably  some  other  more  im- 
portant factor.  In  a  case  of  pruritis  presenting  a  vaginal  discharge,  the  discharge 
has  some  effect  in  keeping  up  the  local  irritation  and  consequently  should  be  stopped. 
But  there  is  no  certainty  that  the  pruritis  will  cease  when  the  discharge  is  stopped, 
hence  caution  in  prognosis  is  necessary.  Other  causes  of  local  irritation,  such  as 
diabetes,  local  skin  diseases  and  uterine  or  ovarian  disease  causing  pelvic  con- 
gestion, must  receive  appropriate  treatment. 

2.  Attend  to  the  general  health.  Regulate  the  bowels  so  that  the  accom- 
panying pelvic  congestion  is  diminished.  Also,  put  the  patient  in  the  best  general 
health,  that  the  condition  of  the  nervous  system  may  be  improved  accordingly. 


462  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

General  sedatives,  for  example,  bromides,  valerian,  hyoscyamus,  may  diminish  the 
Uching  by  their  effect  on  the  nervous  system.  The  anti-neuralgic  remedies  (phe- 
nacetin,  antipyrin,  phenalgin)  may  give  temporary  relief. 

Uric  acid  diathesis,  neurasthenia,  gastro-intestinal  disturbance  and  other  cUs- 
eases  present  must  receive  appropriate  treatment.  The  diet  must  be  looked  after 
sufficiently  to  exclude  alcoholics  and  other  articles  that  tend  to  prolong  skin 
irritation. 

In  some  cases  it  may  be  necessary  to  make  a  complete  change  of  cUmate  and 
surroundings,  in  order  to  satisfactorily  affect  the  patient's  nervous  system  or  some 
existing  diathesis. 

3.  Employ  local  sedative  applications  to  relieve  the  inflammation  and  check 
the  local  nerve  irritation. 

The  various  applications  given  under  vulvitis  and  other  forms  of  vulvar  irri- 
tation may  be  tried.  The  silver  preparations  (silver  nitrate,  argyrol,  protargol) 
are  particularly  effective,  when  there  is  active  superficial  inflammation.  If  fol- 
licular inflammation  is  present,  the  inflamed  follicles  may  be  emptied  by  puncture 
and  the  small  cavities  touched  with  silver  nitrate  solution  (10%)  or  even  with  the 
silver  nitrate  stick.  The  thorough  apphcations  of  silver  nitrate  solution  (10%) 
or  protargol  (10%)  sometimes  gives  decided  relief  from  pruritis  even  when  no 
inflammation  is  present. 

A  useful  mixture  for  washing  out  the  vagina  and  for  an  external  wash  in  these 
cases  is  the  lead  and  opium  and  carbohc  acid  mixture  (see  Formula?).  Cold  appli- 
cations, such  as  an  ice-bag  or  cloths  wet  in  ice  water,  sometimes  give  relief.  Warm 
sitz-baths  of  plain  water,  taken  two  to  four  times  daily,  aid  in  keeping  the  parts 
clean  and  also  tend  to  relieve  the  local  inflammation  and  irritation.  Instead  of 
plain  water  the  vaginal  wash  just  mentioned  may  be  used  in  the  sitz-bath.  In 
some  cases  the  addition  of  ordinary  bran  seems  to  increase  the  soothing  effect  of 
tiie  sitz-bath.  The  patient  may  remain  in  the  sitz-bath  from  10  to  30  minutes,  the 
fluid  being  occasionally  injected  into  the  vagina  if  there  is  much  internal  irritation. 

Most  cases  require  additional  applications  which  are  more  strongly  sedative 
or  ane.sthetic  or  stimulating,  as  the  case  may  be. 

Skene  recommends  the  following,  each  of  which  has  been  used  with  benefit. 
Bichloride  in  almond  oil  (see  Formulae),  morphine  and  chalk  powder  (see  Formu- 
la), opium  and  aconite  mixture  (see  Formula;).  Of  these  preparations,  the  bi- 
chloride in  almond  oil  proved  beneficial  in  the  largest  number  of  cases.  When  this 
fails,  iodoform  in  ether  (1  to  4)  or  carbolic  acid  and  tincture  of  iodine  (equal  parts) 
may  be  applied  by  the  physician. 

The  iodoform  in  ether  is  applied  by  means  of  an  atomizer.  By  using  strong  air 
pressure  the  solution  is  forced  into  all  the  folds  of  the  epidermis  or  mucous  mem- 
brane. The  ether  evaporates,  leaving  a  fine  coating  of  iodoform  over  the  whole 
surface.  This  nearly  always  relieves  considerably  and,  if  applied  frequently,  is 
curative  in  some  cases.  The  carbolic  and  iodine  mixture  is  applied  thoroughly 
to  all  the  involved  surface  by  means  of  a  camels  hair  brush  or  a  small  piece  of  cotton 
on  an  applicator.  This  is  very  effective  in  relieving  the  pruritis,  but  is  liable  to 
cause  considerable  local  irritation  and  dermatitis.  It  should  not  be  reapplied 
until  the  irritation  from  the  first  application  has  subsided. 


trp:atment  for  pruritis  46y 

Skene  gives  an  account  of  one  case  of  severe  pruritis  in  which  he  used  the  carboli" 
and  iodine  mixture  with  the  ordiiuiry  method  of  application,  as  given  above,  but 
found  it  difficult  to  get  the  medicuie  into  all  the  irregularities.  Consequently,  he 
applied  it  by  means  of  the  atomizer,  using  high  pressure.  The  first  effect  was  a 
sharp  pain  followed  by  numbness  of  the  parts  and  relief  from  the  itching.  Later, 
there  was  great  irritation  and  pain,  and  the  superficial  layers  of  the  skin  and  mu- 
cous mem])rane  came  off,  as  though  they  had  been  blistered.  The  patient  stated, 
however,  that  even  when  the  pain  from  the  irritation  was  at  its  heigiit,  it  caused 
far  less  suffering  than  the  previous  itching.  When  the  patient  recovered  from  the 
treatment,  the  itching  did  not  return  for  several  weeks  and  then  only  in  slight 
degi-ee.  The  same  api^licat  ion  was  again  made  to  several  spots  tliat  were  itching, 
care  being  taken  not  to  cover  more  than  a  small  area.  The  result  of  the  two  appli- 
cations was  a  complete  recovery  from  the  intolerable  pruritis. 

In  irritation  from  dia])eti(^  urine,  bismuth  snbuitrate,  either  alone  or  mixed  with 
an  equal  quantity  of  prepared  chalk,  is  an  excellent  application.  Direct  the  pa- 
tient to  prevent,  as  far  as  possible,  the  urine  from  running  over  the  parts,  and 
immediately  after  urination  to  wash  the  parts  with  a  carbolic  wash  and  then  dry 
carefully  and  then  dust  on  the  powder  freely. 

Ravogli  recommends  the  following  additional  measures  in  vulvar  irritation  from 
various  causes: 

A  carbolic  and  sulphur  ointment  (see  Formulae)  when  the  initation  is  due  to 
diabetic  urine.  For  the  same  purpose  a  liniment  of  oil  and  lime  water,  with  2% 
to  4%  ichthyol  added,  is  recommended,  to  be  applied  when  the  patient  can 
remain  in  bed.  When  the  patient  cannot  remain  in  bed,  some  protective  ointment 
such  as  benzoated  oxide  of  zinc  ointment  or  the  zinc  and  subcarbonate  of  bismuth 
ointment  (see  Formulae)  may  be  used. 

When  eczema  is  present,  direct  the  patient  to  irrigate  the  vagina  wdth  a  5% 
solution  of  borax  twice  daily.  Every  other  day  insert  into  the  vagina  a  tampon 
saturated  in  a  mixture  of  25%  ichthyol  in  glycerine,  the  tampon  to  be  left  in  the 
vagina  twelve  hours.  To  relieve  the  itching  and  sterilize  the  skin  apply  the  car- 
bolic and  alcohol  mixture  (see  Formulae).  This  causes  some  burning  at  first  but 
soon  affords  relief.  After  this  application  direct  the  patient  to  apply  pieces  of  lint 
saturated  with  the  ichthyol  and  almond  oil  liniment  (see  Formulae).  When  the 
itching  has  disappeared  and  the  eczema  is  nearly  well,  the  ichthyol  liniment  may 
be  discontinued  and  the  zinc  and  bismuth  ointment  (see  Formulae)  used.  After 
the  eczema  has  disappeared,  the  parts  should  be  frequently  cleansed  with  a  car- 
bolic solution  and  dusted  freely  with  some  chying  powder. 

When  there  is  persistent  follicular  inflammation,  the  carboic  and  ])ismuth  an<l 
mercury  ointment  (see  Formulae)  is  useful.  Ichthyol  is  also  highly  recommended 
either  as  the  liniment  (see  Formulae)  or  in  the  form  of  a  salve  (10%)  in  association 
with  the  zinc  ointment  and  2%  beta-nap hthol.  Ointments  containing  sulphur 
also  are  recommended,  such  as  Lassar's  paste  (see  Formulae).  The  result  of 
treatment  for  pruritis  vulvae  is  very  uncertain  and  measures  that  are  efficient  in 
one  case  may  fail  completely  in  another.  I  have  obtained  good  results  from  an 
ointment  of  chloretone  (10%).  Much  relief  may  be  afforded  also  by  orthoform 
ointment  (10%)  and  by  cocaine  ointment  (1%  to  10%).  Electricity  has  given 
relief  in  some  cases,  and  it  is  well  to  try  it  in  a  variety  of  applications. 


464  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

The  X-ray  treatment,  when  available,  should  be  given  a  thorough  trial  in  severe 
pruritis  cases,  before  resorting  to  operative  measures. 

4.  Operations.  In  certain  intractable  cases,  particularly  those  accompanied 
by  evidences  of  kraurosis  vulvae,  relief  was  afforded  by  excision  of  the  involved 
tissues  as  previously  described,  after  the  other  measures  had  failed.  When  incision 
is  resorted  to,  it  is  as  a  rule  necessary  to  remove  the  labia  minora  and  the  clitoris 
with  its  prepuce,  and  often  the  inner  portions  of  the  labia  majora. 

Another  operative  measure  which  has  brought  about  recovery  in  some  cases, 
is  resection  of  the  internal  pudic  nerve.  The  nerve  is  reached  by  an  antero-pos- 
terior  incision  midway  between  the  tuberosity  of  the  ischium  and  the  anus.  Care 
must  be  taken  that  the  innervation  of  the  rectum  be  not  damaged,  with  resulting 
incontinence  of  feces. 

HYPERESTHESIA  OF  THE  VAGINAL  ENTRANCE. 

The  structures  surrounding  the  vaginal  orifice  may  be  so  hyperesthetic,  that 
coitus  is  very  painful  and  in  some  cases  impossible.  Occasionally  the  parts  are  so 
tender  and  the  nervous  irritability  so  marked  that  attempts  at  sexual  intercourse 
cause  a  spasm  of  the  muscles  surrounding  the  vaginal  opening,  including  the 
levator  ani.     This  spasmodic  condition  is  known  as  "  vaginismus." 

Causes.  Hyperesthesia  of  the  vaginal  entrance  occurs  most  frequently  in  ner- 
vous young  women,  newly  married,  or  in  women  near  the  menopause.  The  causes 
of  this  marked  hyper-sensitiveness  are  as  follows: 

a.  Urethral  caruncle  or  inflammation  about  the  meatus. 

b.  Painful  fissures  about  the  vaginal  orifice  or  about  the  anus. 

c.  Inflammation  of  a  rigid  hymen  or  of  remnants  of  a  hymen. 

d.  Abnormal  form  of  vulva  by  which  the  penis  is  directed  in  the  wrong  direction, 
particularly  against  the  urethra,  causing  much  pain. 

e.  Neuromata  on  remnants  of  the  hymen. 

f.  Neuroses.  In  some  cases,  especially  in  women  near  the  menopause,  no  local 
cause  for  the  marked  sensitiveness  can  be  discovered  and  it  is  apparently  due  to 
some  functional  disturbance  of  the  nerves. 

Treatment.     The  treatment  may  be  presented  in  the  following  steps: 

1.  Reduce  the  general  nervous  irritability  by  sedatives  and  relieve  the  pelvic 
congestion  by  laxatives. 

2.  Remove  all  local  lesions  that  cause  irritation.  Abrasions,  fissures  and  areas 
of  inflammation  must  be  made  to  heal.  The  various  therapeutic  measures  for 
these  conditions  have  been  described.  A  rigid  hymen  must  be  treated  by  stretch- 
ing or  incision  or  excision. 

Neuromata  sometimes  develop  in  remnants  of  the  hymen  about  the  posterior 
commissure,  and  occasionally  in  the  tissues  about  the  meatus  or  the  clitoris.  There 
may  be  one  or  more  nodules,  varying  in  size  from  the  head  of  a  pin  to  a  bean. 
They  are  exceedingly  sensitive  when  touched  in  the  examination.  They  should 
be  excised  deeply  and  the  small  wound  closed  by  one  or  two,  sutures  if  there  is  much 
bleeding.  Ten  to  twenty  drops  of  cocaine  solution  (i%)  injected  under  the  nodule 
a  few  minutes  before  excision  diminishes  the  pain.     If  the  nodule  can  be  easily 


HYPERESTHKSIA  OK  VAC.INAT.  KNTUANCE  465 

raised  it  may  be  clippcMl  off  with  l]\c.  scissors.      If  it  is  imbedded  in  the  tissues  it 
must  be  dissected  out  with  a  knife. 

3.  Employ  local  sedative  applications.  A  hot  carl^olic  douche,  once  or  twice 
daily,  may  diminish  the  sensitiveness  of  the  parts.  The  various  sedative  meas- 
ures mentioned  under  vulvitis  and  pruritis  vulvae  may  be  employed.  The  10% 
chloretone  ointment  may  give  much  relief.  A  cocaine  suppository  (see  Fornuilffi) 
introduced  into  the  vagina  a  few  minutes  before  may  diminish  or  remove  the  pain 
of  coitus.  A  cocaine  ointment  (5%)  may  be  applied  to  the  sensitive  parts  with  the 
same  effect.  The  ointment  applied  freely  serves  also  to  lubricate  the  parts  and  in 
that  way  helps  to  diminish  the  pain. 

When  this  affection  occurs  in  a  young  married  woman,  if  the  pateint  becomes 
pregnant  and  is  delivered  at  term,  the  vaginismus  will  probably  he  heard  of  no 
more.  Consequently,  if  by  temporary  measures  the  pain  of  sexual  intercourse 
can  be  overcome  for  a  few  weeks,  pregnancy  may  take  place  and  a  permanent  cure 
follow. 

In  some  mild  cases  the  patient  may  be  given  relief  or  even  cured  by  introducing 
a  bivalve  speculum  every  second  or  third  day,  and  very  slowly  and  carefully  stretch- 
ing the  parts  until  decided  discomfort  is  noticed.  No  severe  pain  should  be  caused, 
as  the  patient  may  be  frightened  and  made  worse.  After  the  gentle  stretching, 
a  small  tampon,  with  the  upper  end  soaked  in  boro-glyceride,  should  be  placed  in 
the  upper  part  of  the  vagina.  This  tampon  should  be  small  at  first  but  as  new  ones 
are  placed  they  may  be  gradually  increased  in  size  until  the  vagina  is  firmly 
filled,  but  the  tampon  must  not  come  low  enough  to  make  troublesome  pressure 
on  the  vaginal  entrance. 

4.  Forcible  dilatation.  When  the  milder  measures  fail  to  give  relief  the  patient 
should  be  anesthetized  and  the  vaginal  entrance  forcibly  stretched  with  the  fingers 
or  with  a  ]:)i valve  speculum.  The  speculum  is  introduced  and  opened  and  then 
withdrawn  while  the  blades  are  widely  separated.  Any  abrasions  remaining  after 
the  stretching  should  be  touched  with  carbolic  acid  and  an  antiseptic  dressing,  of 
absorbent  cotton  or  gauze,  should  be  kept  over  the  vulva  until  all  the  abrasions 
have  healed.  After  the  stretching,  a  vaginal  plug  of  glass  is  introduced  every  day 
for  a  time  to  prevent  contraction  of  the  healing  tissues. 

When  forcibly  stretching  the  vaginal  orifice,  if  there  are  fibers  that  do  not  yield 
readily  they  may  be  divided  subcutaneously  with  a  bistoury.  In  some  cases  in 
which  the  opening  is  narrow  and  the  perineum  rigid,  it  is  advisable  to  employ  the 
method  devised  by  Sims,  namely,  excision  of  a  V-shaped  piece  of  tissue  at  the  pos- 
terior margin  of  the  vaginal  opening.  This  gives  a  result  corresponding  to  slight 
'aceration  of  the  perineum  in  labor  and  is  of  much  benefit.  It  gives  a  larger  vaginal 
•opening  but  does  not  interfere  to  any  extent  with  the  integi'ity  of  the  pelvic  floor, 
m  those  cases  in  which  the  hyperesthesia  is  due  to  abrasions,  principally  in  young 
women,  this  forcible  stretching  is  very  effctive. 

In  the  purely  neurotic  cases,  chiefly  in  women  near  the  menopause,  it  may  pro- 
duce but  little  result.  Such  cases  are  exceedingly  rebellious  and  occasionally  per- 
sist in  spite  of  all  treatment.  Complete  excision  of  the  skin  covering  all  hyperes- 
thetic  areas,  gives  temporary  relief,  but  the  trouble  may  return  after  a  few  months. 

In  the  intractable  cases,  the  treatment  that  promises  most  relief  is  excision  of 


466  DISEASES  OF  EXTERNAL  GENITALS  AND  VAGINA 

the  skin  over  the  affected  areas  and  then,  or  as  soon  as  the  parts  have  healed  suffi- 
ciently, send  the  patient  away  from  home  to  where  there  will  be  an  enjoyable  change 
of  air  and  scenery  and  environment.  Advise  regular  and  moderate  exercise  and 
a  nourishing  but  unstimulating  diet.  Forbid  excessive  exercise  and  forbid  sexual 
intercourse  or  sexual  excitement.  Regulate  the  bowels,  give  tonics  and  allay  the 
local  disturbance  temporarily  by  the  cleansing  and  sedative  measures  previously 
described.  Resection  of  the  internal  pudic  nerve  may  give  relief  in  an  intractable 
case. 

ADHESIONS  OF  PREPUCE. 

Not  infrequently  in  infants  adhesions  are  found  between  the  glans  of  the  clitoris 
and  the  prepuce.  In  some  cases  the  adhesions  are  extensive  (Fig.  223)  and  much 
irritation  is  produced  by  retained  secretion.  In  such  a  case  the  adhesions  should 
be  separated.  A  strong  solution  of  cocaine  (10%  to  20%)  is  applied  to  the  parts 
for  five  minutes,  then  with  a  blunt  dissector,  the  adhesions  are  broken,  the  glans 
thoroughly  exposed  (Fig.  224)  and  the  part  cleansed  and  smeared  with  carbolized 
zinc  ointment  (2%)  or  with  carbolized  vaseline  (2%).  Every  day  or  two  the  pre- 
puce should  be  pushed  back  and  the  antiseptic  ointment  applied,  until  there  is  no 
further  danger  of  the  formation  of  new  adhesions. 


ADHESIONS  OF  LABIA. 

The  labia  minora  are  occasionally  found  adherent.  This  condition  may  be  con- 
genital or  acquired.  In  the  latter  case,  the  cause  is  inflammation  or  ulceration  of 
various  kinds,  producing  raw  surfaces  which  come  in  contact  and  grow  together 
(Fig.  225).  The  adhesions  are  usualy  found  in  the  unmarried,  as  the  parts  are  not 
so  frequently  disturbed,  and  especially  in  children  and  in  the  aged,  when  consider- 
able imtation  may  persist  without  attracting  notice.  The  adhesions  between  the 
lal^ia  are  easily  broken  if  recent,  but  later  the  adherent  surfaces  become  firmly 
united  l^y  connective  tissue  and  can  be  separated  only  with  the  knife.  The  treat- 
ment, when  the  adhesions  are  recent  and  weak,  is  to  break  them  with  a  probe  or 
other  blunt  instrument,  separate  the  labia  and  keep  them  apart  mth  pledgets  of 
cotton.  Treat  the  affected  sm-faces  as  indicated  by  the  inflammation  or  ulceration 
present.  When  the  adhesions  are  old  and  firm,  the  parts  may  be  separated  with 
the  knife  or  scissors  or  the  line  of  union,  with  some  of  the  thickened  tissue  on  each 
side,  may  be  excised,  sutures  being  then  introduced  to  check  the  hemorrhage  and 
close  the  raw  furfaces.  If  there  is  a  marked  tendency  of  the  vaginal  orifice  to  con- 
tract from  scar-tissue,  it  may  be  stretched  at  the  same  time,  and  a  glass  plug  worn 
for  a  time  afterward  ii.  necessarv. 


46"; 


CHAPTER   Y. 

LACERATION  AND  FISTULA 

of  the  Pelvic  Floor,  Perineum,  External  Genitals  and  Vagina. 

POINTS  IN  ANATOMY. 

The  term  "pelvic  floor"  is  applied  to  that  gi-oup  of  structures  which  closes  in  the 
pelvic  outlet  and  supports  the  structures  above  it.  The  muscular  and  fascial 
layers  are  shown  in  Fig.  487.  The  important  structures — those  that  give  strength 
to  the  floor — are  principally  the  levator  ani  muscles  and  the  recto-vesical  fascia. 
There  are,  however,  a  number  of  other  stuctures  in  this  locality,  and  probably  the 
l)est  way  to  consider  them  systematically  is  to  take  them  up  in  the  order  in  which 
they  are  met  with  in  the  regular  dissection  of  this  region. 

Having  the  body  in  position  for  dissection  of  the  perineum  and  making  obser- 
vation before  the  integument  is  removed,  it  is  found  that  the  area  between  the 
coccyx  and  the  pubes  is  filled  in  as  follows,  beginning  in  front: 

The  vulva  or  external  genitals. 
The  perineum. 

The  anus  and  the    ischio-rectal  fossa  of  each   side  (covered  with  in- 
tegument) . 

The  vulva  and  perineum  occupy  the  anterior  lialf  of  the  space.  The  anus  is 
situated  at  al^out  the  center,  and  around  it  to  the  sides  and  behind,  are  the  ischio- 
rectal fossae. 

The  external  genitals  have  been  described  in  chapter  iv.  The  perineum  is  the 
wedge  of  tissue  situated  between  the  vagina  and  the  lower  portion  of  the  rectum. 
Seen  in  the  antero-posterior  section,  it  is  roughly  triangular  (Figs.  1,  3,  593). 
In  some  cases  it  is  somewhat  quadrilateral.  It  separates  the  vaginal  opening  from 
the  rectal  opening,  but  does  not  form  an  essential  part  of  the  the  real  supporting 
floor  of  the  pelvis. 

The  removal  of  the  skin  and  superficial  fat  and  fascia,  exposes  the  perineal  fascia 
the  sphincter  ani  muscle  and  the  ischio-rectal  fossa  of  each  side.  Each  ischio- 
rectal fossa  is  bordered  behind  and  at  the  outer  side  by  the  gluteus  maximus  muscle. 

Reflecting  the  perineal  fascia  there  are  exposed,  the  sphincter  vaginae  and  the 
transversus  perinei  muscles  (Fig.  488).  The  transversus  perinei  muscle  of  each 
side  is  a  small  muscular  band  which  arises  from  the  ischial  tuberosity  and,  extend- 
ing inward,  joins  at  the  center  of  the  perineum  with  the  muscle  of  the  opposite  side 
and  with  the  sphincter  vaginae  and  with  the  sphincter  ani  muscles.  When  the 
perineum  is  torn,  the  action  of  all  these  muscles,  particularly  of  the  transverse 
muscles,  is  to  draw  the  torn  surfaces  outward  and  keep  them  apart. 


468 


LACERATIONS  AND  FISTUL.E 


When  all  the  superficial  tissues,  including  the  clitoris  and  the  crura,  are  cleared 
away,  then  there  is  exposed  the  real  pelvic  floor — the  supporting  structures. 
These  structures  are,  the  levator  ani  muscles,  one  on  each  side  (Fig.  489)  called  also 
the  levator  ani  et  vaginae,  and  the  fascia  above  and  below  them  (Figs.  490,  491). 
The  fascia  under  the  muscle  is  thin  and  is  called  the  "levator  fascia,"  while  the 
strong  fascia  above  the  muscle  is  called  the  "recto- vesical"  (Fig.  490).  The 
levator  ani  muscles,  arising  from  each  side  of  the  pelvis  and  joining  in  the  median 
line,  form  a  sling  which  holds  up  the  vagina  and  rectum  and  at  the  same  time  holds 
their  lower  ends  forward  under  the  pubic  arch. 


Fig.  487.  A  diap;rammatif"  representation  of  an  antero-posterior  section  of  the  pelvis, 
sli'iwinK  (lie  various  Fascial  Layers  of  the  Pelvic  floor.  (Dickinson— Ajyiericaii  Text- 
boo/:  of  Obstetrics.) 


Each  levator  ani  muscle  arises  in  front  from  the  posterior  surface  of  the  pubic 
bone,  behind  from  the  spine  of  tiie  isciiium  and  between  these  points  from  the 
"white  line"  (Fig.  87)  tiiat  marks  the  division  of  the  pelvic  fascia.  The  anterior 
portion  of  the  muscle  passes  downward  ;tiid  toward  the  median  line  and  unites 
with  a  corresponding  portion  of  (he  muscle  of  the  opposite  side.  Some  of  the 
fibers  unite  with  the    U)wer  part  of    the  vagina,  some  with  the  lower  part  of  the 


POINTS  IN    ANATOMY 


-!()'.) 


rectum,  some  between  the  vagina  and  rectum  and  many  of  them  back  of   tlie  rec- 
tum.    The  most  posterior  fibers  of  the  nmscle  unite  with  the  coccyx.    Lying  Ijack 


Suspensory  ligament  of  clitoris 
Glans  ciitoridis 

Por.c  i-:r  supLrficiil  perlne-il  n 
Fnscia  lata 
or  pudendal  n. 


1 


a!  perineal  n.t 

Anal  fisci 


1  in'.r 

ITrinsverst:  pc 


Fig.  488.     View  of  the  superficial  structures  from  belo%v.     Showmt;  the  Spiinctcr  Am  Mu:=dc,  the  Tiau^\CK~Uo 
Perinei  Muscles  and  the  Arteries  and  Nen'es.     {Deaver— Surgical  Anatomy.) 


470 


LACERATIONS  AND  FISTULA 


Fig.  489.     The   superficial    structures    removed,  exposing    the   Levator   Ani  et  Vaginae  Muscles.      (Savage- 
Anatomy  of  Female  Pelvic  Organs.) 


V\r,.  490,     The  Levator   Ani  Musclea  rcmovcdi  cxpo.sing  the  strong  Rccto-vcsical  Fascia.     (Savage— vt»((<om,(/ 
of  Female  Pelcic  Organs.) 


rOiNTS  IN   ANATONii 


471 


Fig.  491.  The  Pelvic  81ing.  It  is  composed  of  the  Levator  Ani 
Muscles  and  the  Fascia  above  and  below  them.  Its  attachment  to  the 
rectum  is  here  shown  but  the  vagina  is  not  shown.  (Kelly — Operative 
Gynecology.) 


Fig.  492.     The    Pelvic    Sling,  formed    by    the   Levator    Ani 
Muscles.      (Dickinson— America;!.  Text-book  of  Obstetrics.) 


Fig.  49.3.  .\ction3  of  the  Pelvic  Sling.  It 
tends  to  draw  the  vaginal  opening  and  the 
anus  forward  under  the  pubic  arch,  at  the  same 
time  that  it  supports  them.  (Kelly — Operative 
Gynecology.) 


472 


LACERATIONS  AND   FISTUL-E 


Fig.  494.  The  Pelvic  Sling,  from  above.  The  observer  is  supposed  to  be  standing  at  the  right  side  of  the 
cadaver  and  looking  into  the  pelvis.  The  pelvic  contents  have  been  removed  in  order  to  show  the  pelvic  floor. 
{Deaver— Surgical  Anatomy.) 


LACERATION  OF  THE  PELVIC  I'LOOK  473 

of  the  posterior  part  of  the  levator  ani  muscle  is  the  coccygeus  muscle.  The  action 
of  the  levator  muscles,  in  conjunction  with  the  fascia  above  and  below  them,  is  to 
hold  forward  the  lower  end  of  the  rectum  and  vagina  dose  to  the  symphysis  puljis, 
and  at  the  same  time  to  form  a  sling  which  closes  the  pelvic  outlet  and  sui)p()rts 
the  organs  above  (Figs.  491,  492,  493,  494).  Waldeyer  has  given  this  the  very 
appropriate  designation  of  "  diaphragm  of  the  pelvis." 

When  the  muscles  and  fasciae  are  torn,  the  effect  is  two-fold: 

1.  The  sling  is  lengthened  and  does  not  furnish  the  suppport  it  previously  did. 

2.  The  vaginal  and  rectal  openings  (the  weak  places  in  the  pelvic  floor)  are 
allowed  to  sink  backward  into  the  line  of  pressure,  so  that  the  weight  from  above, 
which  formerly  fell  on  the  muscle  and  fascia,  now  falls  on  the  openings. 

In  repairing  the  pelvic  floor,  the  following  two  things  must  be  accomplished: 

1.  The  pelvic  sling  must  be  shortened,  so  that  the  slack  is  taken  up. 

2.  The  vaginal  opening  must  be  brought  forward  under  the  pubic  arch,  out  of 
the  line  of  direct  pressure. 


LACERATION  OF  PELVIC  FLOOR  AND  PERINEUM. 

Laceration  of  the  pelvic  floor  is  laceration  of  the  supporting  structures  at  the 
pelvic  outlet,  principally  the  levator  ani  muscles  and  the  fascia  immediately 
above  and  below  them.  This  is  usually  accompanied  by  laceration  of  the  vaginal 
wall.  Laceration  of  the  perineum  is  laceration  of  the  wedge  of  tissue  placed  be- 
tween the  lower  portion  of  the  vagina  and  the  rectum.  This  is  usually  accom- 
panied by  laceration  of  the  fourchette  and  of  the  lower  part  of  the  vaginal  wall. 

In  nearly  all  the  important  injuries  at  the  pelvic  outlet,  the  laceration  involves 
both  the  pelvic  floor  and  the  perineum,  consequently  it  is  most  convenient  to  con- 
sider these  two  lesions  together  under  the  term  that  heads  this  subject.  As  the 
injury  of  the  pelvic  floor  is  the  more  important  lesion,  the  perineal  tear  being  in 
most  cases  of  secondary  importance,  the  injury  is  frequently  spoken  of  simply  as 
laceration  of  the  pelvic  floor.  It  is  known  also  as  "relaxation  of  the  pelvic  floor" 
and  as  "relaxation  of  the  pelvic  outlet." 

ETIOLOGY. 

The  usual  cause  of  laceration  of  the  pelvic  floor  and  perineum  is  child=bii*th. 

As  the  child's  head  passes  through  the  pelvic  outlet,  the  structures  are  greatly 
stretched  and,  if  it  is  the  first  baby,  there  is  frequently  more  or  less  laceration.  In 
many  cases  the  laceration  is  so  slight  as  to  be  hardly  noticeable.  In  some  cases  it 
is  moderate  and  will  cause  trouble  later  if  not  repaired.  In  a  few  cases  it  is  very 
severe,  extending  deeply  into  the  sides  of  the  pelvis  or  into  the  rectum  or  into  both 
regions. 


474 


LACERATIONS  AND  FISTULA 


PATHOLOGY  AND  DIAGNOSIS. 

To  understand  the  pathology  of  this  affection,  certain  points  in  anatomy  must 
be  kept  in  mind.  The  real  pelvic  floor,  that  is  the  part  that  supports  the  organs 
above  is  formed  by  the  two  levator  ani  muscles  with  the  layer  of  fascia  immediately 
above  and  below  (Figs.  487,  491,  492,  493).  The  recto-vesical  fascia  is  a  strong 
fibrous  layer,  probably  the  strongest  and  most  resistant  single  element  in  the  pelvic 
floor.  It  evidently  is  the  structure  which  furnishes  continuous  support  to  the 
organs  above,  for  the  muscles  of  the  floor  can  not  be  constantly  tense. 

The  perineum  takes  little  part  in  the  formation  of  the  pelvic  flooor,  as  it  lies 
below  and  outside  of  the  supporting  sling.  The  perineum  may  be  torn  with  prac- 
tically no  damage  to  the  pelvic  floor,  providing  the  anterior  part  of  the  levator 
ani  muscles  or  adjacent  fasciae  are  not  involved  in  the  tear.  It  is  not  the  tearing 
of  the  perineum  that  destroys  the  integrity  of  the  pelvic  floor,  but  the  tearing  and 
stretching  of  the  musculo-fibrous  sling  which  passes  back  of  the  rectum  and  holds 
both  the  rectum  and  vagina  well  up  under  the  symphysis  (Fig.  493). 

The  pathological  changes  and  the  diagnostic  points  are  best  considered  together 
under  the  different  varieties  of  laceration.  Immediately  after  the  delivery  of  the 
child  and  placenta,  search  should  be  made  for  tears  of  the  perineum  and  pelvic  floor. 


Varieties  of  Laceration. 

There  are  several  varieties  of  laceration,  differing  in  extent  and  location. 

1.  There  may  be  a  slight  tear  of    the  perineum  only,  involving  less  than  half 
of  the  perineum.     The  fourchette  is  torn  and  also  part  of  the  skin  covering  the 

perineum  and  also  the  lower 
portion  of  the  posterior  vag- 
inal wall.  Such  a  tear  has 
practically  no  effect  on  the 
pelvic  floor,  as  the  pelvic  floor 
proper  is  not  involved.  It  is 
called  a  laceration  of  the  peri- 
neum of  the  "first  degi-ee." 

2.  There  may  be  a  tear  down 
past  the  middle  of  the  peri- 
neum— laceration  of  "second 
degree."  This  may  involve 
the  perineum  only,  in  which 
case  there  is  no  decided  dam- 
age to  the  pelvic  floor.  Us- 
ually, however,  the  tear  ex- 
tends up  the  vaginal  sulcus 
of  one  or  both  sides  and  in- 
N'olves  the  front  part  of  the 
levator  ani  muscle  and  recto- 

Fic.49.5.    A  Deep  Laceration,  cxtendiriK  up  cauL  vaginal  Miku.s       vo'^iinl   fq«5P?n   rFio-    40"=;^        Thc^. 
and  involving  the  Pelvic  SliriK  on  each  siflfi      (r.illian,    Practical       ^ '-'^i^  <*!  ^'I'S.^i'l  U  ife-  I'^o;  .       J.  lie 

Gynecology/.)  Ulcerations  involving  the  mus- 


L 

A 

V 

j-m\ 

^P^tcium     j^JH 

mSmtSwH 

.j^^'  "■  "'"' -  :r^ 

IL/^^^  V 

L^^ 

-lifl^m 

^^r    f 

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VARIETIES  OF  PELVIC-FLOOR  LACERATIONS 


475 


cular  and  fibrous  structures  at  the  sides  of  the  vagina  are  sometimes  spoken  of  as 
"  lateral ' '  or  "  transverse  "  lacerations.  The  laceration  of  the  muscle  and  fascia  may 
he  open,  coinimiiiicating  with  a  vaginal  tear,  or  subcutaneous,  with  no  vaginal  tear 
in  the  immediate  vicinity.  By  washing  the  blood  out  of  the  vagina  with  a  hot 
douche  and  exploring  with  the  finger,  the  tear  in  the  vaginal  wall  may  be  felt  and 
traced  to  its  full  extent.  When  its  extent  can  not  l^e  satisfactorily  made  out  with 
the  fingers  alone,  the  vagina  may  be  held  open  with  retractors  and  the  length  of  the 
tear  ascertained  by  inspection.  The  tear  may,  in  exceptional  cases,  extend  around 
the  sphincter  ani,  on  one  or  both  sides,  without  extending  through  that  muscle 
into  the  rectum. 

3.  There  may  be  a  tear 
of  the  perineum  through 
the  sphincter  ani  muscle 
into  the  rectum — lacera- 
tion of  the  "third  de- 
gree" (Fig.  496).  This 
of  course  occurs  only  in 
exceptional  cases  and  is 
usually  accompanied  by 
one  or  more  deep  tears 
of  the  pelvic  floor. 

4.  The  perineum  may 
be  torn  only  slightly  ex- 
ternally, while  there  is  a 
deep  tear  inside  involv- 
ing the  vaginal  wall  and 
the  deeper  structures. 
Such  a  tear  may  be  over- 
looked vmless  careful  ex- 
ploration is  made  after 
labor. 

5.  The  vaginal  wall  and  perineum  may  be  torn,  the  rim  of  the  vaginal  orifice 
reinaining  intact.  This  is  known  as  central  rupture  of  the  perineum  (Fig.  235). 
It  is  very  unusual. 

The  five  varieties  of  laceration  just  given  are  easily  recognized  at  the  close  of 
labor  and  should  be  repaired  at  once. 

6.  In  some  cases  the  pelvic  sling  is  seriously  damaged  without  any  open  tear 
of  the  perineum  or  vaginal  wall.  In  such  a  case  there  is  no  open  wound  to  be  seen 
or  felt.  In  fact,  in  such  a  case  it  is  difficult  or  impossible  to  make  a  positive  diag- 
nosis of  laceration  at  the  time,  because  of  the  marked  stretching  and  distortion  of 
the  parts  that  normally  takes  place  and  is  followed  by  no  trouble.  In  such  a  case, 
the  individual  tears  in  the  muscles  are  probably  small  and  numerous.  The  diag- 
nosis is  made  later,  when  it  is  found  that  the  pelvic  floor  is  weak  and  does  not  fur- 
nish proper  support.  Such  cases  are,  by  some  writers,  designated  as  "relaxation 
of  the  pelvic  floor."  But  I  see  no  reason  why  the  term  "relaxation"  shovdd  be 
applied  to  this  form  of  tear  any  more  than  to  the  open  tear.     Of  course,  a  condition 


Fig.  496.  A  Laceration  extendin<;  directly  through  the  Sphincter 
Ani  muscle  and  other  structures  between  the  vagina  and  rectum. 
The  Levator  Ani  muscles  are  not  involved.  (GiWiam— Practical 
Gynecology.) 


476  LACERATIONS  AND  FISTULiE 

of  relaxation  is  found  after  all  severe  injuries  of  the  pelvic  floor,  but  that  simply 
means  that  there  has  been  a  tear,  either  open  or  subcutaneous,  and  the  condition 
should  be  considered  under  the  head  of  laceration. 

Skene  mentions  having  seen  three  cases  of  such  subcutaneous  injury  in  which 
the  sphincter  ani  was  also  torn.  Each  patient  had  incontinence  of  feces,,  and  yet 
the  most  careful  examination  failed  to  show  any  evidence  of  an  open  tear,  either 
over  the  perineum  or  in  the  vagina. 

Results  of  the  Laceration. 

In  laceration  of  the  pelvic  floor,  not  repaired  at  once,  there  is  decided  increase 
in  the  chance  of  infection  following  labor.  If  the  patient  escapes  sepsis,  there  is 
not  much  discomfort  until  she  gets  up  and  about,  for  as  long  as  she  is  lying  in  bed 
the  loss  of  support  at  the  pelvic  outlet  is  but  Uttle  noticed.  Of  course,  if  the  tear 
has  extended  into  the  rectum  there  is  incontinence  of  feces. 

After  the  patient  has  been  up  and  about  the  house  for  a  short  time,  she  notices 
decided  weakness  in  the  pelvis,  which  becomes  more  marked  as  she  becomes  other- 
wise stronger  and  attempts  more  work.  She  complains  of  a  dragging  weight  in  the 
pelvis  and  of  back-ache.  As  the  uterus  sinks  in  the  pelvis,  the  cervix  frequently 
goes  forward,  as  well  as  downward,  and  the  fundus  goes  backward  in  retroversion. 
This  tendency  of  the  cervix  to  sink  downward  and  forward  is  increased  by  the 
inflammation  and  subinvolution  resulting  from  cervical  lacerations,  received  in  the 
same  labor. 

On  inspection,  it  is  found  that,  instead  of  a  normal  vaginal  opening,  the  vaginal 
outlet  is  relaxed — that  is,  it  is  open  and  without  tone  or  resistance.  The  two  index 
fingers  introduced  into  the  opening  (Fig.  59)  may  be  carried  to  the  sides  of  the  pubic 
arch  with  but  little  resistance.  If  now  the  patient  be  directed  to  bear  down  or 
strain,  as  in  defecation,  the  sinking  oind  protrusion  of  the  parts  become  more  marked, 
and  the  relaxation  of  the  floor  is  more  apparent.  Another  method  of  testing  the 
relaxation  of  the  floor  is  shown  in  Figs.  57  and  58.  The  margin  of  the  untorn  por- 
tion of  the  pelvic  sling  may  often  be  felt  on  one  or  both  sides  in  the  vagina  some 
distance  from  the  vaginal  orifice. 

Though  in  most  cases  of  laceration,  the  vaginal  orifice  is  widened  and  patulous 
and  the  remaining  perineum  very  narrow,  in  some  cases  the  skin  surface  of  the 
perineum  is  intact  and  the  vaginal  orifice  is  small  and  placed  at  the  normal  distance 
from  the  anus.  A  superficial  examination  of  such  a  patient  would  lead  to  the  con- 
clusion that  the  pelvic  floor  was  intact,  but  examination  within  the  vagina  (Fig. 
57)  shows  marked  relaxation,  establishing  the  fact  of  serious  laceration  of  the  pelvic 
sling. 

Subinvolution  of  the  vagina  with  more  or  less  atrophy  of  the  pelvic  muscles, 
results  from  unrepaired  laceration  of  the  pelvic  floor. 

Effects  of  the  Loss  of  Support. 

The  cervix  sinks  into  the  pelvis  and  comes  forward  and  the  fundus  uteri  fre- 
quently goes  backward  into  retrodisplacement  (Fig.  343).  Also,  the  whole  uterus 
lies  too  low  in  the  pelvis,  constituting  prolapse  of  the  uterus  (Fig.  287). 


LACERATION  INTO  THE  RECTUM  477 

As  the  damaged  pelvic  floor  and  other  supports  of  the  uterus  gradually  stretch 
more,  the  uterus  may  sink  so  low  that  the  (-ervix  appears  at  the  vagnial  opening 
(Fig.  288).  As  the  uterus  sinks  lower  the  vaginal  opening  enlarges  and  the  vaginal 
walls  roll  outward,  forming  anterior  or  posterior  colpocele  (Fig.  239). 

With  the  prolapsed  posterior  vaginal  wall,  sometimes  the  anterior  wall  of  the 
rectum  is  found,  forming  a  rectocele  (Figs.  240,  241,  244,  245).  An  appearance 
resembling  rectocele  may  be  produced  by  prolapse  of  a  thickened  vaginal  wall. 
There  is  areolar  hyperplasia  and  often  considerable  venous  dilatation,  giving  quite 
a  large  projecting  mass,  but  without  displacement  of  the  anterior  rectal  wall. 
Whether  or  not  rectocele  is  really  present,  is  easily  ascertained  by  rectal  examina- 
tion, to  determine  if  the  anterior  rectal  wall  is  pouched  forward  with  the  vaginal 
wall  (Figs.  241,  246,  247).  In  some  cases  of  rectocele,  a  large  pouch  is  formed  and 
interferes  much  with  emptying  the  rectum,  it  being  necessary  for  the  patient  to 
push  back  the  protruding  rectocele  to  secure  satisfactory  bowel  movement  (Fig. 
245). 

If  the  base  of  the  bladder  follows  the  prolapsing  anterior  vaginal  wall,  the 
condition  is  known  as  cystocele  (Figs.  240,  241,  242).  It  can  be  determined  by 
a  sound  or  stiff  catheter  in  the  bladder  (Fig.  243).  Sometimes  a  supposed  cysto- 
cele is  found  to  be  only  vaginal  wall.  In  marked  cystocele,  a  large  pouch  is  formed 
at  the  floor  of  the  bladder,  in  which  residual  urine  remains  and  decomposes, 
causing  much  bladder  irritation.  It  is  sometimes  necessary  for  the  patient  to 
push  back  the  protruding  cystocele  before  a  satisfactory  evacuation  of  the 
bladder  can  be  secured.  Straining  at  defecation  or  urination  greatly  aggravates 
the  cystocele.  In  some  cases  both  rectocele  and  cy,  tocele  are  present  (Figs. 
240,  241). 

When  the  vaginal  entrance  is  relaxed,  air  can  enter  the  vagina,  and  it  is  some- 
times expelled  with  more  or  less  noise,  which  is  very  annoying  to  the  patient. 
This  phenomenon  is  known  as  "flatus  vaginalis."  It  is  merely  a  symptom  of  re- 
laxed vaginal  orifice.  It  was  formerly  described  under  the  queer  title  of  "  garrulity 
of  the  vulva." 

Laceration  of  Sphincter  Ani  Muscle. 

If'  the  laceration  of  the  pelvic  outlet  has  extended  through  the  sphincter  ani 
muscle,  there  will  be  incontinence  of  feces  and  intestinal  gases,  making  the  patient 
miserable  and  excluding  her  from  society.  When  completely  torn,  the  sphincter 
ani  retracts — sometimes  to  such  an  extent  that  it  scarcely  reaches  half  way  around 
the  rectal  opening.  It  may  be  felt  as  a  thick  cord  at  the  postej-ior  part  of 
opening.  A  slight  dimple,  or  retraction  of  tissue,  frequently  marks  the  location 
of  each  end  (Fig.  234).  A  small  area  of  the  rectal  mucous  membrane  may  be 
visible  as  a  red  inflamed-looking  spot,  marking  the  situation  of  the  anus  (Figs. 
232,  233). 

If  the  sphincter  muscle  is  not  completely  torn,  a  few  fibers  remaining  intact,  the 
patient  may  be  able,  even  from  the  first,  to  retain  solid  feces — that  is,  there  is  only 
partial  incontinence.  In  these  cases  of  partial  rupture  of  the  sphincter,  and  also 
in  cases  of  complete  rupture  in  which  the  muscle  was  paralyzed  by  the  stretching 
before  rupture  and  the  ends  of  the  muscles  or  tissues  close  to  the  muscle  lay  in 
contact  and  became  partially  united,  the  patient  has  control  of  the  bowels  excent 


478  Lacerations  and  fistdl^e 

when  diarrhoea  is  present.  In  some  cases  the  patient  has  control  over  feces,  both 
solid  and  liquid,  but  there  is  incontinence  of  gases. 

In  some  of  these  cases  of  partial  incontinence,  a  wide  area  of  scar  tissue  lies 
between  the  ends  of  tho  muscle.  In  such,  do  not  be  misled  into  the  belief  that 
there  has  not  been  a  rupture  of  the  sphincter.  The  rupture  of  the  muscle  is  prac- 
tically complete  and  the  ends  must  be  denuded  and  united  the  same  as  if  the 
patient  had  no  control  of  the  bowels. 

A  laceration  through  the  sphincter  ani  muscle  and  recto-vaginal  septum,  does 
not  necessarily  mean  that  there  has  been  great  damage  to  the  pelvic  sling.  The 
principal  part  of  the  sling  passes  back  of  the  rectum,  not  between  it  and  the  vagina 
(Fig.  493). 

If  the  rectal  tear  is  accompanied  by  deep  lacerations  at  the  sides  of  the  vagina, 
involving  the  levator  ani  muscles,  then  there  will  be  marked  loss  of  support  in  the 
pelvic  floor  and  consequent  relaxation  of  the  vaginal  outlet.  Such  accompanying 
deep  lateral  lacerations  do  frequently  occur  with  the  result  mentioned.  But  in 
some  cases,  the  tear  in  the  median  line  into  the  rectum  seems  to  have  been  the  only 
serious  damage.  In  such  a  case,  the  incontinence  of  feces  is  the  only  troublesome 
symptom,  there  being  no  evidence  of  want  of  support  for  the  pelvic  organs. 

This  essential  difference  between  median  and  lateral  lacerations,  explains  why 
it  is  that  some  cases  of  complete  perineal  laceration  with  incontinence  are  not  ac- 
companied with  the  prolapse  of  the  uterus  and  vaginal  walls,  so  frequently  seen  in 
incomplete  perineal  lacerations.  On  the  old  theory  that  the  perineum  was  the 
important  supporting  structure  at  the  pelvic  outlet,  this  class  of  cases  was  inex- 
plicable. Since  the  facts  in  regard  to  the  anatomy  and  function  of  the  component 
parts  of  the  pelvic  floor  have  become  known,  these  cases  are  easily  explained. 

Complications. 

In  old  lacerations  of  the  pelvic  floor,  there  are  frequently  present  vaginal  discharge, 
painful  menstruation,  irregular  menstruation,  excessive  menstruation,  attacks  of 
severe  pelvic  pain,  dyspareunia,  sterility,  abortions,  various  reflex  phenomena  and 
general  poor  health.  These  symptoms  however  are  due  principally  to  associated 
diseases,  some  of  which  may  be  traced  to  the  laceration.  The  diseases  which  are 
frequently  associated  with  laceration  of  the  pelvic  floor  are: 

Laceration  of  cervix. 
Chronic  endometritis. 
Subinvolution. 
Retrodisplacement  of  uterus. 
Prolapsus  uteri. 
Chronic  salpingitis. 

All  lesions  present  should  bo  found  and  tlieir  .severity  determined  before  opera- 
tive treatment  is  undertaken. 

Treatment. 

In  a  fresh  laceration  of  the  pelvic  floor  or  perineum  in  labor,  the  rule  is  to  repair 
the  injury  at  once.     Even  though  the  tear  is  not  deep  enough  to  damage  the  pelvic 


TREATMENT  OF  PELVIC-FLOOR  LACERATIONS  479 

floor,  it  should  be  repaired,  for  every  laceration  closed  lessens  to  that  extent  the 
chance  of  infection.  For  the  same  reason,  tears  of  the  anterior  vaginal  wall  or  of 
the  vulvr,  should  be  repaired  at  once.  The  details  of  this  immediate  repair  belong 
to  obstetric  work,  and  need  not  be  considered  here. 

In  an  old  laceration  repair  of  the  pelvic  floor,  months  or  years  after  the  injury, 
is  a  much  more  tedious  operation  and  requires  more  preparation  and  skill.  The 
parts  have  been  stretched  out  of  their  normal  relations  and  the  contraction  of  the 
scar-tissue  has  drawn  mucous  membrane  over  the  damaged  areas. 

Palliative  measures.  In  a  case  of  old  laceration,  waiting  for  operation  or  in 
which  operation  is  not  advisal^le,  considerable  temporary  relief  may  l)e  afforded 
by  the  knee-chest  posture,  taken  for  a  few  minutes  morning  and  evening.  In  some 
cases  the  patient  is  made  more  comfortable  Ijy  some  one  of  the  pessaries  useful  in 
retrodisplacement  or  prolapse  (see  pages  328  and  340).  Vaginal  tamponade 
also  gives  some  temporary  relief.  Astringent  douches,  rest  in  the  recumljent  pos- 
ture several  times  daily,  and  the  various  means  for  reducing  pelvic  congestion  are 
useful  palliative  measures. 

Operative  Treatment.  For  permanent  relief,  operation  is  necessary.  Many 
operative  procedures  have  been  designed,  the  principal  ones  of  which  are  mentioned 
below. 

Object  of  the  Operation. 

The  object  of  the  operation  is  to  restore  a  strong  sling  across  the  pelvic  outlet, 
to  support  the  organs  above.  To  restore  the  integrity  of  the  pelvic  floor,  the 
following  two  things  must  be  accomplished: 

1.  The  musculo-fibrous  pelvic  sling  must  be  shortened  so  that  the  slack  is  taken 
up. 

2.  The  vaginal  opening  (the  necessarily  weak  place  in  the  pelvic  floor)  must  be 
brought  forward  under  the  puljic  arch  and,  consequently,  out  of  the  line  of  direct 
pressure  from  above. 

Ptepairing  the  perineum  is  known  as  "perineorrhaphy."  Suturing  the  vaginal 
wall  is  designated  as  ''colporrhaphy." 

Though  the  literal  meaning  of  each  of  these  terms  is  limited,  they  are  by  common 
consent  used  to  indicate  the  general  suturing  usually  necessary  in  these  cases. 
A  more  accurate  and  comprehensive  designation  for  this  operation  is  "repair  of  the 
pelvic  floor."  This  operation  comes  under  the  general  class  known  as  "plastic 
operations,"  which  includes  also  repair  of  cervix,  operation  for  cystocele  and 
closure  of  fistulae. 

Indications  and  Contra=indications. 

The  indications  for  repair  of  the  pelvic  floor  are: 

1.  Decided  symptoms  of  loss  of  support  at  the  pelvic  outlet — «uch  a.s  dragging 
weight  in  the  pelvis,  backache  and  a  feeling  of  weakness  there. 

2.  Prolapse  of  the  vaginal  walls,  with  or  without  cystocele  or  rectocele. 

3.  Prolapse  of  the  uterus. 

4.  Movable  retrodi.splacement  in  which  a  pessary  can  not  be  retained,  on  account 
of  the  laceration  at  the  vaginal  outlet. 

5.  Incontinence  of  feces,  indicating  damage  to  the  sphincter  ani. 


480  LACERATIONS  AND  FISTULA 

The  contra=indicationsare: 

1.  Absence  of  decided  symptoms  of  loss  of  suppport  in  the  pelvic  floor. 

2.  Marked  kidney  lesion  or  other  serious  disease  contra-indicating  anesthesia. 

3.  Hemophilia.  Skene  encountered  three  such  patients.  Two  of  them  were 
operated  on  before  the  bleeding  tendency  was  discovered,  the  result  being  failure  of 
che  operation  in  each  case  and,  as  he  remarks,  "  the  development  of  extreme  cau- 
tion on  the  part  of  the  operator  in  selecting  cases  in  the  future."  In  the  third 
case,  the  fact  that  the  patient  was  a  "bleeder"  was  elicited  in  getting  the  his- 
tory, and  consequently  the  operation  was  not  advised. 

4.  Uterine  disease  with  an  infectious  discharge.  The  uterine  disease  should  be 
treated  and  the  infectious  discharge  checked  before  any  plastic  operation  is  under- 
taken. 

Preparations  for  the  Operation. 

The  preparations  for  repair  of  the  pelvic  floor  may  be  divided  into  (1)  pre- 
paration of  the  patient,  (2)  preparation  of  the  instruments  and  dressings  and  (3) 
preparation  of  the  operator  and  assisstants. 

1.  Preparation  of  the  Patient.  The  general  preparations  as  for  any  operation 
requiring  an  anesthetic,  are  carried  out  (see  preliminary  preparation  of  patient  for 
Abdominal  Section — chapter  xv). 

It  is  well  to  time  the  operation  so  that  the  healing  surfaces  will  not  be  disturbed 
by  the  menstrual  flow  for  ten  days  or  two  weeks  after  operation.  Consequently, 
the  preferable  time  for  the  operation  is  from  three  to  ten  days  after  menstruation. 
The  antiseptic  preparation  of  the  patient  in  this  particular  operation  is  confined 
to  the  vagina  and  adjacent  regions.  The  patient  should  receive  an  antiseptic 
douche  once  or  twice  daily  up  to  the  time  of  operation.  Several  hours  before 
operation  or  the  day  before,  the  field  of  operation  should  be  shaved.  The  shaving 
includes  the  pubic  and  perineal  regions  and  the  adjacent  portions  of  the  thighs 
and  buttocks.  The  surfaces  are  then  washed  with  green  soap  and  warm  water 
with  a  soft  brush  or  cotton-balls.  The  soap  is  then  washed  off  with  sterile  water 
and  the  surfaces  are  washed  with  bichloride  solution  (1-2000).  The  surfaces  are 
then  dried  with  a  sterile  towel  or  cotton-balls  and  covered  with  a  large  piece  of 
cotton  wrung  out  of  bichloride  solution  (1-5000). 

After  the  patient  is  under  the  anesthetic,  the  vagina  is  scrubbed  thoroughly 
with  the  warm  soap-solution,  using  cotton-balls  held  in  long  forceps.  Two  fingers 
of  the  left  hand  are  introduced  into  the  vagina  and  all  portions  of  the  vaginal  walls 
are  put  on  the  stretch  as  they  are  scrubbed  (Figs.  574,  575).  A  brush  is  too  harsh 
for  this  purpose  and  it  can  not  be  handled  as  satisfactorily  as  the  cotton  in  the 
forceps.  The  external  genitals  and  the  entire  field  of  operation  is  again  scrubbed 
with  the  soap-solution:  The  soap  is  then  washed  off  with  sterile  water,  and  the 
vagina  and  external  surfaces  are  scrubbed  with  bichloride  solution  (1-2000). 
The  sterile  cloths  are  then  placed  about  the  field  and  the  patient  is  ready  for  opera- 
tion. 

2.  Preparation  of  Instruments  and  Dressings.  The  details  of  the  antiseptic 
preparation  of  the  instruments  and  dressings  are  given  under  Preparations  for 
Abdominal  Section,  in  chapter  xv. 


INSTRUMENTS  FOR  REPAIR  OF  PELVIC  FLOOR 


481 


Fig.  497.  Instruments  for  Repair  of  the  Pelvic  Floor:  a,  short  tenaculum-forceps  (have  four);  b,  bistoury; 
c,  long  tissue-forceps;  d,  long  scissors  for  denuding;  e,  vaginal  dressing-forceps  for  sponging  (have  two):  f, 
hemostat-forceps  for  holding  suture  ends  or  catching  bleeding  points  (have  eight);  g,  right-angled  vaginal 
retractor  (have  two);  h,  short  scissors  for  cutting  suture  material;  i,  Sims'  needle-holder;  j,  number  2,  20-day 
catgut  (have  six  tubes)  and  strong  full-curved  round-point  needles  (have  four);  k,  eilkworm-gut  (have  eight 
strands)  and  large  full-curved  Hagedorn  needles  (have  four).  The  large  needles  may  be  used  without  a 
needle-holder. 


The  instruments  required  for  repair  of  the  pelvic  floor  are  shown  in  Fig.  497. 
There  should  be  at  hand  also: 

Leg  holders,  in  the  form  of  uprights  attached  to  the  table  (Fig.  572). 

Perineal  pad. 

Fountain  syringe. 

Rubber  apron  for  operator. 

Gowns  for  operator  and  assistants. 

For  the  anesthetist  there  should  be: 

Ether-inhaler  and  chloroform-inhaler. 

Ether  and  chloroform. 

Tongue  forceps. 

Vaseline,  for  patient's  face. 

Hypodermic  syringe. 

Necessary  stimulants. 

3.  Preparation  of  Operator  and  Assistants.  The  antiseptic  and  aseptic  prepara- 
tion for  the  operator  and  assistants  for  operative  work  in  general,  is  given  in  detail 
under  Preparations  for  Abdominal  Section  (chapter  xv).  It  is  not  so  important 
to  use  rubber  gloves  here  as  in  intra-peritoneal  work  and,  as  they  interfere  more  or 
less  with  the  manipulations,  they  may  be  dispensed  with  if  desired. 

Two  assistants,  beside  the  anesthetist,  are  needed  for  rapid  work,  one  to  expose 
the  various  portions  of  the  field  of  operation  and  the  other  to  sponge  away  the  blood 
and  handle  sutures.     A  good  nurse  does  well  as  one  of  these  assistants. 


482 


LACERATIONS  AND  FlSTULiE 


Emmet's  Operation. 

There  are  three  principal  operations  for  repair  of  the  pelvic  floor— (a)  Emmet's 
operation,  the  area  of  denudation  of  which  is  sometimes  referred  to  as  the  ''  butter- 
fly denudation"  because  of  its  shape,  (b)  Hegar's  operation,  in  which  comes  the 
"triangular  denudation"  and  (c)  Tait's  operation,  in  which  the  vaginal  mucosa 
over  the  injured  area  is  raised  as  a  flap,  thus  splitting  the  lower  part  of  the  recto- 
vaginal septum  into  an  upper  and  a  lower  flap— hence  the  name  "flap-splitting 
operation,"  by  which  it  is  frequently  designated. 

Emmet's  operation  was  worked  out  by  Dr.  T.  A.  Emmet  about  twenty-five 
years  ago  (completed  operation  published  in  1883)  and,  with  some  modifications, 


'   *^' 


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\\'    >^ 


s^:^' 


■'^- 


£L 


A  B 

Fig.  498.  Recent  Lacerations  in  Labor.  A.  Laceration  involving  the  perineum 
and  extending  up  the  riglit  vaginal  sulcu.s.  B.  More  severe  Laceration,  involving 
the  perineum  and  extending  up  both  vaginal  .sulci.  (Dickinson — American  Text-book 
of  Obstetrics.) 


it  stands  today  as  one  of  the  best   operations  for  repair  of  laceration  of  the  pelvic 
floor. 

It  tends,  more  than  any  other,  to  restore  exactly  the  relations  of  the  vaginal  wall 
and  perineum,  as  shown  in  the  following  explanation.  A  laceration  usually  affects 
first  the  perineum  in  the  median  line,  and  as  the  tear  extends  into  the  vagina 
it  passes  up  the  sulcus  of  one  or  both  sides,  as  shown  in  Fig.  498.  For  convenience 
the  apex  of  the  vaginal  flap  (central  flap.  Fig.  498-B)  may  be  called  "a."  On  the 
lateral  flaps,  the  point  made  by  the  junction  of  the  vaginal  and  perineal  portion  of 
the  flap  may  be  designated  Ijy  "r,"  for  the  flap  on  the  patient's  right  side,  and  by 
"c"  for  the  left  side  (Fig.  506).  Now  in  the  repair  of  the  injury,  these  three 
points  should  be  brought   together,  to  form  the  lower  part  of  the  restored  vagi- 


STEPS  IN  EMMET'S  OPERATION 


488 


nal  entrance.  In  the  fresh  laceration,  exten(lin<!;  up  the  sulcus  of  each  side  (Fiji;. 
498-B),  the  parts  are  not  yet  cUstorted  by  displacement,  beyond  a  slight  separa- 
tion, and  the  location  of  these  three  points  is  very  evident. 

In  the  old  tear,  however,  the  parts  are  much  distorted  by  displacement  and  scar- 
tissue  has  drawn  the  mucous  membrane  over  the  injured  area,  as  indicated  in 
Figs.  239  and  499.  These  three  points  are  now  difficult  to  identify,  but  they  must 
be  located  and  brought  together.  The  apex  of  the  vaginal  flap  is  indicated  in 
Fig.  499  by  "a,"  while  the  points  "r"  and  " c"  are  indicated  by  a  finger  on  each 
side. 

In  the  operation,  the  vaginal  sulcus  between  "r"  and  "a"  and  also  the  sulcus 
between  "c"  and  "a,"  along  with  the  perineum  and  vaginal  entrance,  are  denuded 
sufficiently  to  allow  access  to  and  approximation  of  the  torn  and  separated  tissues 
of  the  pelvic  floor.     And   as  the  operation    is 
completed,  the  points  "a"  and  "r"  and  " c" 
come  together,  as  shown  in  Figs.  50G    and  509. 

1.  Selecting  the  points.  The  patient  is 
anethetized,  the  hips  brought  slightly  over  the 
elid  of  the  table  (Fig.  573),  the  legs  fastened  out 
of  the  way  by  the  supports,  the  parts  thoroughly 
Cleansed  (Figs.  574,  575)  and  the  vicinity  of  the 
field  covered  with  sterile  cloths. 

The  point  "  a  "  is  found  by  catching  the  prom- 
inent part  of  the  protruding  vaginal  wall  (Fig. 
499)  with  a  tenaculum-forceps  and  raising  it 
to  the  anterior  margin  of  the  vaginal  orifice, 
just  beneath  the  meatus.  This  point  must  be 
selected  with  care.  It  constitutes  the  lower 
limit  of  the  restored  posterior  vaginal  wall,  and 
should  be  low  enough  to  permit  of  its  being 
brought  near  the  urethral  meatus  without 
making  the  posterior  vaginal  wall  so  tense  that 
it  pulls  the  cervix  uteri  downward.  If  the  new 
posterior  wall  is  made  so  short  that  it  pulls 
the  cervix  downward,  the  fundus  uteri  will  go 
back  in  time,  causing  troublesome  retroversion. 
On  the  other  hand  the  point  must  be  high 
enough  to  take  the  slack  out  of  the  posterior 
vaginal  wall,  otherwise  the  repair  of  the  pelvic 
floor  will  not  be  sufficiently  thorough. 

Then  select  the  points  ''r"  and  " c"  (Fig.  506)  at  the  margins  of  the  vaginal 
opening.  The  opening  of  the  duct  of  the  vulvo-vaginal  gland  of  each  side  is  tiie  guide 
to  these  points.  On  each  side,  the  tissues  just  below  the  duct  opening,  constituting 
the  points  "r"  and  "  c,"  are  gi-asped  firmly  vnth  one  of  the  short  tenaculum-forceps, 
so  that  they  may  be  retracted  as  required  in  the  subsequent  steps  of  the  operation 
(Fig.  505).  The  lower  remnant  of  the  hymen,  on  each  side,  is  sometimes  evident 
and  serves  to  mark  the  situation  of  the  points  under  consideration.     After  the 

32 


Fig.  499.  Aa  old  Laceration  of  the 
Pelvic  Floor,  involving  botli  vaginal 
sulci,  a.  The  prominent  part  of  the  pro- 
jecting posterior  vaginal  wall.  (Penrose 
—  Diseases  of  JFomen.) 


484 


LACERATIONS  AND  FISTUL.^ 


points  are  gi'asped  they  are  brought  together  temporarily,  as  indicated  in  Fig.  500, 
in  order  to  determine  if  the  restored  vaginal  opening  will  be  sufficiently  small. 

The  next  step  is  to  locate  the  apex  of  the  sulcus-triangle,  which  is  to  be  denuded 
on  each  side.  The  points  "a"  and  ''c,"  which  are  already  caught  with  the  tenac- 
ulum forceps,  are  pulled  upon  so  as  to  cause  a  "hne  of  tension"  from  each,  extend- 
ing up  into  the  vagina,  as  indicated  in  Fig.  501.  These  lines  come  together  some 
distance  up  in  the  vagina,  as  represented  by  the  point  ''b"  in  Fig.  501— the  height 
of  this  point  depending  upon  the  height  of  the  tear.  The  triangular  area  between 

"  these  lines  of  tension  represents  ap- 
proximately the  damaged  area  on 
that  side,  and  constitutes  the  sulcus- 
triangle  to  be  denuded.  The  lines  of 
tension  and  the  point  at  which  they 
come  together  are  determined  by 
touch,  and  then  the  lines  b-a  and  b-c 
are  marked  by  incision  with  the  bis- 
tour3^  The  same  maneuver  is  then 
carried  out  on  the  opposite  side. 

The  damaged  area  usually  extends 
higher  on  one  side  than  on  the  other, 
and  in  some  exceptionally  severe  cases 
extends  nearly  to  the  vaginal  vault. 

2.  Outlining  the  area  for  denuda- 
tion. Before  beginning  the  denuda- 
tion it  is  well  to  completel}'  outline 
the  area  to  be  denuded,  by  incision 
with  the  knife.  During  the  process 
of  denudation  the  parts  are  necessarily 
retracted  in  various  directions  and  the 
relations  disturbed,  and  unless  the 
limits  of  the  area  are  definitely  marked, 
the  area  is  likely  to  be  over-reached 
at  some  points  and  imperfectly  de- 
nuded at  others. 

The  outlining  is  usually  begun  by 
making  an  incision  along  the  lines  of 
tension  in  each  side  of  the  vagina,  as 
mentioned  above.  This  marks  the  limits  of  the  denudation  in  the  vagina.  Then 
the  points  "r"  and  " c"  are  connected  by  a  curved  incision,  that  dips  down  over 
the  perineum  far  enough  to  include  the  damagetl  area  (Figs.  505,  507).  In  most 
of  the  severe  tears,' this  dips  down  very  close  to  the  anus.  This  incision  completes 
the  outline  of  the  area  to  be  denuded,  which  area  has  about  the  shape  shown  in 
Fig.  507. 

3.  Denuding.      This  comprises  removal  of  the  surface-covering  over  the  area 
outlined  and  also  the  excision  of  some  deeper  tissue,  as  explained  below. 

The  most  rapid  and  satisfactory  method  of  removing  the  mucosa  is  by  means 


Fig.  500.  Emmet's  Operation.  Selecting 
the  two  Lateral  Points.  The  two  Lateral 
Points  are  caught  and  brought  together  tem- 
porarily, to  see  how  large  the  repaired  vaginal 
opening  will  be.  (KeUy— Operative  Gynec- 
ology.) 


DENUDING  IN  EMMET'S  OPERATION 


485 


of  the  scissors,  straight  or  curved  as  preferred.  On  account  of  the  bleeding  from 
the  tlenuded  area,  it  is  well  to  begin  at  the  bottom  and  work  upward,  as  the  blood 
will  not  be  so  much  in  the  way.  The  assistant  pulls  upward  and  outward  on  one 
of  the  tenaculum-forceps  at  the  sides,  so  as  to  cause  a  line  of  tension  extending 
down  over  the  danuiged  perineum.  The  operator  picks  up  the  line  of  teasion  at 
some  convenient  point  on  the  perineal  portion  of  the  outlined  area,  and  cuts  off 
the  tense  sti-ip  of  tissue,  as  indicated  in  Figs.  502  and  512.  This  is  repeated  until 
the  lower  portion  of  the  area  is  denuded.  Then  the  points  "a,"  and  "c"  are  sepa- 
rated by  traction  ou  the  attached  tenaculum-forceps,  and  the  left  sulcus-triangle  is 
denuded  in  the  same  way.     Here  the  fixed  point  is  at  " b"  and  each  strip  of  tissue, 


Fig.  501.  Emmet's  Operation,  show- 
ing the  Lines  of  Tension  at  each  side  of 
the  left  vaginal  sulcus  and  their  point  of 
meeting  at  "b."  (Penrose — Diseases  of 
Women.) 


Fig.  502.  Emmet's  Operation,  show- 
ing the  Method  of  Denuding  the  damaged 
area  in  the  left  vaginal  sulcus.  (Pen- 
rose— Diseases  of  Woinen.) 


as  it  is  being  excised,  is  made  tense  as  indicated  in  Fig.  502.  When  one  sulcus  is 
completely  denuded,  the  same  process  is  carried  out  in  the  other  sulcus  (Fig.  503), 

In  the  process  of  denuding,  the  lines  of  traction  and  the  direction  of  cutting  may 
be  varied  as  found  most  convenient.  When  the  surface-covering  has  been  com- 
pletely removed,  the  area  has  approximately  the  appearance  shown  in  Fig.  507. 

The  next  step  is  to  make  the  deep  excision  of  tissue  in  the  outer  side  of  each 
sulcus.  This  is  to  remove  the  principal  part  of  the  scar-tissue  and  other  connective 
tissue  lying  between  the  torn  ends  of  the  pelvic  sling,  so  that  when  the  deep  sutures 
are  passed  and  tied,  the  torn  portions  of  the  sling  may  be  brought  together.  The 
reason  for  the  deep  excision  of  tissue  is  shown  in  Fig.  504. 


486 


LACERATIONS  AND  FISTULA 


It  is  carried  out  by  gi-asping  the  tissues  firmly  in  the  lateral  portion  of  the  denuded 
area  and  drawing  them  out  so  that  they  may  be  clipped  off  with  the  scissors,  as 
indicated  in  Fig.  505.  In  this  illustration  the  handle  of  the  scissors  should  be 
brought  farther  to  the  front,  so  that  the  points  would  cut  more  deeply  into  the  lat- 
eral tissues.     One  or  more  thick  strips  of  tissue  are  removed  from  the  region, 


Fig.  503.  Emmet's  Operation.  Diagrammatic  representation 
of  how  the  mucosa  is  removed  in  strips,  by  following  the  lines 
of  tension.     (GilMaim— Practical  Gynecology.) 


enough  to  accomplish  approximately  the  object  explained  in  Fig.  504,  and  then 
similar  strips  are  removed  from  the  f)pposite  side. 

This  excision  of  deep  tissue  causes  free  bleeding,  but  the  bleeding  vessels  are 
caught  with  artery  forceps  and  later  included  in  the  deep  sutures. 

Care  must  be  taken  in  the  excision  of  tissue  and  in  passing  the  deep  sutures  that 
the  rectum  is  not  injured.  Keep  well  to  the  lateral  regions  of  the  pelvis  and  away 
from  the  rectum. 


THE  EXCISION  OF  DEEP  TISSUES 


487 


The  removal  of  the  intervening  tissue  and  the  approximation  of  the  separated 
ends  of  the  pelvic  sling  are  accomplished  more  or  less  perfectly  as  the  operation  is 
more  or  less  perfectly  carried  out.  The  fact  that  the  sling  is  really  shortenetl  and 
the  pelvic  floor  accordingly  restored,  can  be  demonstrated  by  making  a  digital 
examination  at  the  completion  of  the  operation.    The  result  of  the  operation  is  not 


A 


Fig.  504.  Explanation  of  the  Excision  of  Deep  Tissues  at  tlie  injured  portion  of  the  Pelvic  Sling.  1.  Pelvic 
Sling,  composed  of  the  levator  ani  muscles  and  the  fascia  above  and  below  ;  m.  Vaginal  Mucosa  ;  s.  Scar- 
tissue  between  the  torn  and  separated  ends  of  the  Pelvic  Sling.  A.  Before  Denudation.  B.  .\fter  Denuda- 
tion, the  vaginal  mucosa  having  been  removed  over  the  injured  area.  The  scar-tissue  still  separates  the  torn 
ends  of  the  pelvic  sling.  C.  After  the  Excision  of  Deep  Tissues  in  the  injured  area.  This  shows  also  the 
Course  of  the  Sutures  for  approximating  the  torn  ends  of  the  musculo-fibrous  sling.  D.  The  sutures  tied,  ap- 
proximating the  torn  and  separated  ends  of  the  pelvic  sling. 


^ply  a  narrowing  of  the  vaginal  outlet  nor  only  a  restoration  of  the  perineum, 
but  the  vagina  is  lifted  forward  and  a  firm  support  is  formed,  outside  of  its  walls 
as  far  up  as  the  Operation  extends.  One  cause  of  failure  to  secure  the  desired  result 
is  that  the  excision  of  tissue  is  not  continued  far  enough  up  the  sulcus  towards  the 
cervix  and,  also,  that  not  sufficient  tissue  is  excised  at  the  sides  of  the  vaginal  sulci 


LACERATIONS  AND  FISTULAE 


to  permit  efficient  approximation  of  the  separated  ends  of  the  pelvic  sling.  It  is 
not  necessary  to  remove  all  the  tissue  lying  between  the  separated  ends  of  the 
levator  ani,  but  it  is  necessary  to  remove  enough  of  it  to  shorten  the  pelvic  sling 
sufficiently  to  take  up  the  slack. 


Fig.  505.  Emmet's  Operation.  Indicating  the  Method  of  Remov- 
ing the  Deep  Tissue  from  the  outer  side  of  the  denuded  area  in  each 
vaginal  sulcus.  The  handle  of  the  scissors  should  come  more  to  the 
front,  to  indicate  that  the  points  cut  deeper  into  the  lateral  tissues. 


ExPLANATOHY  NoTE  FOR  FiG.  506.     The  General  Scheme  for  Suturing  in  the  Emmet  Operation. 

A.  The  Inside  Sutures  Passed,  but  not  yet  tied.  These  sutures  may  be  interrupted  or  continuous,  or  if  jire- 
ferred,  the  deeper  parts  of  the  wounds  may  baajiproximated  by  buried  sutures.  The  course  of  the  "  crown  suture" 
is  here  indicated,  but  it  is  usually  not  passed  until  later. 

B.  The  Inside  Sutures  Tied  and  the  Outside  Sutures  Passed,  including  the  Crown  Suture.  Tlie  "crown  suture" 
brings  together  the  points  r,  a,  c.     It  is  usually  passed  last. 

C.  The  Outside  Sutures  Tied,  exceijt  the  Crown  Suture.  The  tying  of  the  Crown  Suture  completes  the  ap- 
proximation. 

D.  The  Additional  Sutures  required  wlien  Die  tear  extends  into  the  Rectum.  The  rent  in  the  rectal  wall  is 
closed  b.v  sutures  Nos.  1,  2  and  3.  These  are  passed  from  the  rectal  suiface  and  may  be  of  catgut  or  fine  silk. 
Suture  No.  4  is  passed  from  the  slcin  surface.  It  is  a  strong  sutuie  of  silkworm-gut  and  approximates  the- ends  of 
the  s])hincter  ani  muscle  and  also  the  tissues  above  the  rectal  tear  along  its  whole  length.  Care  should  be  taken  in 
pa.ssing  it  to  catch  the  retracted  sphincter  ends  and  also  the  tissues  all  the  way  to  above  the  apex  of  tne  rectal 
tear,  as  here  iiulicated.  liefore  this  suture  is  tied,  the  torn  and  retracted  ends  of  the  sphincter  ani  muscle 
should  be  brought  together  by  one  or  two  buried  catgut  sutures,  as  shown  in  Figs.  510  and  511. 


SUTURING  IN  KMMET'S  OPKRATION 


489 


F,g./\ 


F'B-B 


^'^  ^  ^         Fig.D  ^ 

Fig  506.     .The    General    Scheme    of    Suturing  in  Emmet's  Operation.       See  Explanatory  Note  at  bottom  of 
preceding  page. 


490 


1.ACERATIONS  AND  FISTULtE 


This  deep  excision  of  tissue  in  the  sulcus  of  each  side,  was  not  embodied  by  Em- 
met in  his  operation.  It  is  a  later  development,  but  it  is  simply  a  more  thorough 
carrying  out  of  his  original  idea  that  the  operation  must  extend  into  and  unite 
the  torn  structures  at  the  sides  of  the  vagina.  After  completing  the  superficial 
denudation  and  the  deep  excision  of  tissue  and  checking  the  hemorrhage,  the  sutur- 
ing is  begun. 

4.  Suturing.  The  sutures  are  to  be  passed  so  that  they  will  approximate  the 
surfaces,  as  shown  in  Fig.  506.     The  sutures  closing  the  vaginal  portion  of  the 


Fig.  507.  Emmet's  Oi5er;ition.  Giving  a  general 
idea  of  the  area  of  Denudation  and  the  directions 
in  which  the  sutures  are  passed.  TPryor — Opera- 
tive Gynecology.') 


wound  are  conveniently  designated  as  "inside;  sutures,"   and  those  closing  the 
perineal  portion  of  the  wound  as  "  outside  sutures." 

All  inside  sutures  and  all  buried  sutures,  should  be  of  absorbable  material. 
Catgut,  No.  2,  20-day,  is  satisfactory.  Plain  catgut  is  absorbed  too  quickly. 
For  the  outside  sutures,  which  are  to  V^e  removed  at  the  end  of  ten  days,  silkworm- 
gut  is  the  preferable  material. 


SUTURING  I.N   EMMET'S  OPERATION 


491 


The  deeper  parts  may  ])e  approximated  (a)  by  a  single  row  of  iiitei-rupted  sutures, 
as  shown  in  Figs.  50G,  507,  oOS  and  509,  or  (b)  by  a  single  continuous  suture  on 
each  side  extending  to  the  depth  of  the  wound,  or  (o)  by  buried  sutures  to  close  the 
depth  of  the  wound  on  each  .side  and  then  a  continuous  suture  to  close  the  super- 
llcial  portion. 

The  last  mentioned  method  is  tlie  preferable  one.  The  approximation  of  the 
deep  tissues  by  buried  sutures,  both  in  (he  sulcus  of  each  side  and  lower  down  in  the 


Fig.  508.  Emmet's  Operation.  Showing  the  Crown 
Suture  and  the  bringing  together  of  the  points  "a",  "r" 
and"c."  The  vaginal  sulci  have  been  sutured.  Only  two 
of  the  perineal  sutures  are  shown.  (KeWy— Operative 
(lynecology.) 


Fig.  509.  Emmet's  Operation.  All 
sutures  tied.  Showing  the  line  of  ap- 
proximation in  the  perineum  and  in 
each  vaginal  sulcus,  and  showing  also 
the  bringing  together  of  the  points 
"a,"  "r"  and  "c."  (Kelly — Opera- 
tive Gynecology.) 


main  part  of  the  wound,  adds  much  to  the  effectiveness  of  the  operation.  The 
deep  tissues  are  drawn  together  by  these  buried  sutures  so  that  a  good  strong 
pelvic  floor  is  formed,  andl  may  be  felt  even  before  the  superficial  sutures  are 
passed.  These  buried  sutures,  for  approximating  deep  tissues  in  various  parts  of 
the  wound,  are  used  also  in  the  other  forms  of  pelvic-floor  repair.  The  method 
of  their  application  is  practically  the  same  in  all.  They  are  shown  in  Figs.  513, 
514,  518  and  519. 


492  LACERATIONS  AND  FISTULA 

5.  Laceration  into  the  rectum.  When  the  tear  has  extended  into  the  rectum 
(laceration  through  the  sphincter,  "third  degree  tear"),  some  additional  steps  are 
necessary. 

A  more  thorough  preparation  of  the  intestinal  tract  is  required.  For  three  or 
four  days  before  operation,  some  laxative  saline  solution  is  given  every  four  to 
eight  hours,  as  necessary  to  give  two  or  three  good  bowel  movements  daily.  During 
this  preparatory  period  the  patient  should  be  lying  down  most  of  the  time,  and  the 
diet  should  be  Uquids  and  semi-solids,  not  more  than  a  taste  of  soHd  articles  of  food 
being  allowed.  The  laxatives  should  be  stopped  the  day  before  operation  and  the 
lower  bowel  cleared  out  by  a  high  enema  the  evening  before  operation.  The 
next  morning  the  patient  is  given  an  enema,  high  or  low  as  thought  advisable. 
This  last  enema  should  be  given  at  least  two  hours  before  the  time  set  for  the  opera- 
tion. If  given  later,  a  portion  of  it  is  liable  to  be  passed  on  the  table,  annoying 
the  operator  and  jeopardizing  the  asepsis  of  the  operation  wounds. 

The  antiseptic  preparations  are  the  same  as  for  the  other  form  of  tear. 

In  the  technique  of  the  operation,  in  these  cases  of  laceration  of  the  sphincter  ani 
muscle,  there  are  four  special  points,  but  before  considering  these  points  directly, 
attention  should  be  called  to  certain  peculiarities  of  these  tears. 

A  recent  laceration  into  the  rectum  presents  the  condition  shown  in  Fig.  506-D. 
The  torn  and  separated  ends  of  the  sphincter  ani  muscle  are  at  "t"  and  "m." 
The  apex  of  the  tear  in  the  rectal  wall  is  at  "1."  But  after  several  months  a 
decided  change  has  taken  place  in  the  relation  of  the  parts.  By  the  contraction 
of  the  sphincter  muscle,  its  ends  are  still  further  separated,  and  this  tends  to  pull 
down  the  apex  of  the  rectal-wall  tear,  so  that  the  line  t-l-m  becomes  after  a  time, 
almost  a  straight  line.  This  condition  is  well  shown  in  Fig.  234,  the  torn  ends  of 
the  sphincter  being  represented  by  the  small  dimple  at  each  side  of  the  widened  anus. 
This  condition  is  shown  likewise  in  Figs.  232  and  233,  where  may  be  seen  also  the 
usual  protrusion  of  a  small  area  of  rectal  mucosa. 

The  four  special  points  in  the  technique  above  mentioned,  are  as  follows: 

a.  Preliminary  stretching  of  the  contracted  sphincter  ani  muscle  should  be 
carried  out.  The  muscle  may  be  felt  as  a  small  roll  under  the  skin,  in  the  situation 
indicated  in  Figs.  506-D  and  234.  At  the  beginning  of  the  operation,  before  any 
denuding  is  done,  the  contracted  sphincter  muscle  should  be  grasped  firmly  near 
each  end,  between  the  thumb  and  finger,  and  strongly  stretched.  This  overcomes 
the  chronically  shortened  condition  of  the  muscle  and  is  further  advantageous  in 
that  it  produces  temporary  partial  paralysis  of  the  muscle  and  prevents,  for  a  few 
days,  the  tugging  on  the  sutured  ends  which  would  otherwise  take  place.  It  also 
permits  the  escape  of  gas  and  feces  from  the  rectum  with  less  discomfort  to  the 
patient  and  less  danger  to  the  wound. 

b.  The  area  of  denudation  must  be  extended  downward  so  as  to  include  the 
dimple  over  each  end  of  the  torn  sphincter  ani  muscle,  as  shown  in  Fig.  510. 

c.  The  tear  in  the  rectal  wall  must  be  closed  by  a  separate  row  of  sutures.  These 
sutures  may  be  of  catgut  or  fine  silk — ^in  either  case  they  take  care  of  themselves 
and  do  not  need  to  be  removed.  They  are  passed  from  the  rectal  surface  as  indi- 
cated in  Fig.  506-D,  and  when  tied  the  knots  lie  in  the  rectum. 

d.  The  ends  of  the  torn  sphincter  muscle  arc  brought  directly  together.     To  do 


REPAIR  OP  THE  TORN  SPHINCTER  AND 


433 


this  it  is  necessary,  after  the  regiUar  denudation,  to  clip  out  the  scar  tissue  from 
over  the  torn  ends  of  the  muscle.  This  tissue  is  raised,  as  shown  iji  Fig.  510,  and 
clipped  off  with  the  scissors.  This  permits  the  muscle  ends  to  be  brought  directly- 
together  by  one  or  two  buried  sutures  (Fig.  511).  Their  union  is  reinforced  by  the 
lowest  external  suture  of  silkworm-gut,  which  is  carefully  passed  so  as  to  include 
the  ends  of  the  sphincter  muscle  and  the  apex  of  the  tear  in  the  rectal  wall,  as 
indicated  in  Fig.  506-D. 


Fig.  510.  Emmet's  Operation.  The  laceration  has 
involved  the  Sphincter  Ani  Muscle.  The  scar-tissue 
over  each  end  of  the  torn  muscle  is  picked  up  and  ex- 
cised.    {KeUy— Operative  Gynecology.) 


Fig.  511.  Emmet's  Operation.  The  bared  ends 
of  the  torn  Sphincter  Ani  Muscle  have  been  brought 
together  and  united  by  buried  catgut  sutures.  (Kelly — 
Operative  Gynecology.) 


6.  After=Treatment  in  repair  of  the  pelvic  floor.  The  details  of  the  care  of  a 
patient  after  repair  of  the  pelvic  floor  may  be  grouped  as  follows: 

a.  Knees  Together.  For  the  first  twenty-four  hours  after  operation  it  is  well 
to  have  the  patient's  knees  held  together  by  a  bandage  around  them,  a  thick  pad 
of  cotton  being  placed  between  the  knees  to  prevent  discomfort.  After  the  first 
day  or  two,  the  knees  may  be  released,  unless  the  patient  is  very  nervous  and  rest- 
less. Ordinarly,  the  pain  on  separation  of  the  thighs  is  decided  enough  to  prevent 
injurious  separation. 


494  LACERATIONS  AND  FISTULA 

b.  Changing  the  Dressing.  The  genitals  and  pubic  region  must  be  kept 
CO  veered  -^dth  a  large  sterile  dressing'  of  absorbent  cotton  or  gauze.  When  the 
dressing  has  to  be  removed  for  any  cause,  for  example,  to  allow  the  patient  to 
urinate,  the   nurse  should  proceed  as  follows: 

Remove  the  dressing,  slip  the  bed-pan  under  patient  and  allow  her  to  urinate. 
Cleanse  the  genitals  by  pouring  a  1-5000  bichloride  solution  over  them  from  a 
sterile  pitcher  (pitcher-douche) .  Remove  the  bed-pan,  apply  a  fresh  sterile  dress- 
ing and  reapply  the  T-bandage.  If  the  patient  complains  of  persistent  smarting 
from  the  bichloride  solution,  a  weak  carbolic  solution  or  lysol  solution  may  be  used 
instead  of  the  bichloride. 

c.  Relief  of  Pain.  After  a  thorough  repair  of  the  pelvic  floor  there  is,  as  a  rule, 
considerable  pain  for  the  first  few  days.  This  consists  of  superficial  smarting  and 
deep  acheing  and  occasional  sharp  pains  due  to  muscular  action.  All  these  are 
relieved  considerably  by  hot  moist  packs  applied  to  the  perineum.  Disinfect  the 
hands  and  then  take  a  large  thick  piece  of  absorbent  cotton,  as  large  as  the  two 
hands,  soak  in  hot  carbolic  solution  (  i%),  squeeze  it  sufficiently  to  prevent  drip- 
ping and  then  apply  it  while  steaming  to  the  perineum.  Put  a  large  piece  of  oiled- 
silk  over  the  cotton,'  to  keep  in  the  moisture,  and  then  reapply  the  T-bandage. 
Outside  this  it  is  well  to  place  a  hot  water  bag,  to  maintain  the  heat.  This  hot 
application,  changed  as  often  as  it  becomes  cool,  usually  gives  considerable  relief 
and  may  be  used  frequently,  or  if  necessary  almost  continuously,  for  the  first  few 
days. 

If  the  smarting  is  very  troublesome,  carbolic  or  lysol  solution  may  be  used 
for  cleansing  the  parts.  If  the  acheing  and  pain  is  still  sufficiently  troublesome 
to  prevent  rest,  give  sodium  bromide  as  necessary  to  allay  nervousness  and  secure 
sleep,  particularly  at  night.  If  the  shooting  pains  through  the  perineum  are  per- 
sistent, it  may  be  necessary  to  give  codeine  phosphate  hypodermatically  or  by  the 
mouth,  in  half-grain  doses,  repeated  as  often  as  necessary  to  give  rest. 

The  pains  and  soreness  gradually  disappear  and  after  the  first  few  days,  as  a  rule, 
no  sedatives  are  rec^uired. 

d.  Diet.  The  day  after  operation  liquid  diet  is  given,  and  after  that  ordinary 
light  fliet,  until  the  Ijowels  have  moved  freely,  when  regular  diet  is  gi-adually  re- 
sumed. 

When  the  laceration  has  extended  through  the  sphincter  ani,  the  patient  should 
be  kept  on  liquid  diet  exclusively  until  after  the  first  bowel  movement.  In  such  a 
case  there  should  be  no  bowel  movement  for  four  full  days,  anrl  if  necessary  some 
mixture  such  as  bismuth  and  opium  is  given  to  hold  the  bowels  in  check  that 
long. 

e.  Care  of  Bladder.  If  the  patient  can  pass  the  urine  herself,  I  prefer  to  have 
her  do  so.  The  catheter  shf)uld  be  used  only  if  necessary.  Aside  frorn  the  ever- 
present  danger  of  cystitis,  the  use  of  the  catheter  is  a  flisadvantage  in  that  the 
manipulations  necessary  to  catheterization  disturb  the  parts  and  do  more  harm 
than  the  contact  of  healthy  urine,  especially  as  the  urine  is  at  once  removed  by  the 
cleansing  solutif)n. 

In  many  cases  however,  particularly  with  deep  lacerations,  the  patient  can  not 
urinate  at  first  and  must  be  catheterized  for  one  or  more  days.     The  frequency  of 


AFTER-TREATMENT  IN  PELVIC-FLOOR  REPAIR  495 

catheterization  depends  somewhat  on  the  (juantity  of  uiine  secreted.  Ordinarily 
it  is  requiretl  about  every  eight  hours.  For  the  details  of  catheterization  see 
chapter  xvi. 

f.  Vaginal  Douches.  Ordinarily,  I  prefer  not  to  disturb  the  interior  of  the 
vagina  with  douches  for  the  first  three  days.  After  that  it  is  well  to  give  a  bi- 
chloride douche  (1-5000)  or  lysol  douche  once  daily.  In  introducing  the  douche- 
nozzle  the  nurse  should  be  careful  to  carry  the  point  along  the  anterior  vaginal  wall 
so  that  there  may  be  no  chance  of  its  going  into  the  wound  in  the  posterior  wall. 

g.  Care  of  the  Bowels.  After  repair  of  the  ordinary  laceration,  the  bowels 
should  be  moved  in  two  days  by  a  purgative.  Several  hours  after  the  purgative  is 
taken,  when  the  patient  has  a  desire  for  bowel  movement,  an  enema  of  two  ounces 
of  olive  oil  in  a  pint  of  water  may  be  given.  This  softens  the  fecal  masses,  lubri- 
cates the  rectum  and  does  not  cause  the  smarting  that  is  often  so  troublesome 
after  the  ordinary  soap-water  enema.  After  that,  laxatives  should  be  given  as 
necessary  to  secure  one  or  two  bowel-movements  daily. 

In  those  cases  where  it  has  been  necessary  to  repair  the  sphincter  ani  muscle 
and  rectal  wall,  there  should  be  no  bowel  movement  for  four  full  days.  If  neces- 
sary, some  preparation  should  be  given  to  keep  the  bowels  quiet  and  prevent 
movement.  When  it  is  time  for  the  bowels  to  move,  a  purgative  is  given  and  when 
the  desire  for  defecation  comes  on,  two  to  four  ounces  of  olive  oil  should  be  in- 
jected high  into  the  rectum  and  allowed  to  remain  for  some  time.  The  oil  softens 
the  fecal  masses  and  at  the  same  time  lubricates  all  the  surfaces,  so  there  is  much 
less  danger  of  the  rectal  wound  being  torn  open.  When  there  has  been  repair  of 
the  rectal  wall,  the  small  oil  enema  is  better  than  the  large  water  enema,  as  the 
large  quantity  of  water,  if  injected  into  the  rectum  only,  may  stretch  the  wall  and 
open  the  wound.  Great  care  is  necessary  in  giving  the  first  enema  after  repair  of  a 
laceration  extending  into  the  rectum,  and  unless  the  nurse  has  had  experience  in 
such  cases  the  physician  had  better  give  it  himself.  If  the  point  of  the  syringe  is 
directed  too  far  forward  it  is  apt  to  break  open  the  rectal  wound.  On  that  account 
it  is  well  not  to  introduce  the  hard-rubber  syringe  point  into  the  rectum  but  to 
introduce  a  soft-rubber  catheter  and  give  the  injection  of  oil  through  that.  The 
patient  should  be  cautioned  to  avoid  all  straining  efforts  in  defecation.  If  the 
bowels  do  not  move  easily  and  without  straining,  she  should  wait  for  a  repetition 
of  the  needed  enema  or  purgative. 

h.  Removing  the  Sutures.  The  silkworm-gut  sutures  are  removed  in  eight 
to  twelve  days.  By  that  time  they  have  usually  begun  to  cut  into  the  tissues  and 
no  longer  give  support.  If  some  suture  causes  irritation  it  may  be  removed  any 
time  after  the  fifth  day,  but  unless  there  is  marked  irritation  all  the  sutures  should 
be  left  as  long  as  they  give  support,  usually  for  ten  days.  The  inside  sutures  in  the 
vagina  and  in  the  rectum  take  care  of  themselves. 

i.  Getting  Up.  The  patient  should  be  kept  in  bed  three  full  weeks.  She  may 
then  be  allowed  out  of  bed  gradually,  each  day  more  and  more,  so  that  by  the  end 
of  the  fourth  week  she  is  ready  to  leave  the  hospital.  If  the  patient  is  allowed  up 
too  soon,  there  may  be  stretching  of  the  newly-healed  tissues  and  recurrence  of 
the  old  trouble.  It  may  seem  strange  that  the  patient  is  kept  in  bed  longer  than 
for  an  abdominal  section,  but  there  is  good  reason  for  it.     So  much  strain  comes  on 


496 


LACERATIONS  AND  FISTULA 


the  pelvic  sling  as  soon  as  the  patient  assumes  the  upright  posture,  that  stretching 
of  the  repaired  sling  is  very  likely  to  take  place  unless  the  scar-tissue  has  had  time 
to  become  firm. 

j.  General  after-care.  It  is  a  good  plan  to  take  advantage  of  the  patient's 
confinement  to  bed  to  improve  her  general  health.  Many  of  these  patients  are  weak, 
anemic,  nervous  and  generally  "run  down,"  as  a  result  of  the  long  continued  pelvic 
distress.  In  such  a  case,  after  the  first  three  or  four  days,  put  the  patient  on  a 
good  tonic,  containing  iron  and  such  additional  drugs  as  may  be  indicated  in  the 
particular  case.  The  patient  may  be  given  large  quantities  of  milk  in  addition 
to  the  other  food,  both  at  regular  meal  times  and  between  meals  and  at  night,  the 
amount  of  nourishment  taken  each  twenty-four  hours  being  gradually  increased  as 
the  patient  can  bear  it.  In  many  cases  it  is  of  much  benefit  to  employ  massage, 
passive  movements,  salt-rubs  and  the  various  other  measures  used  in  the  "rest 
cure"  for  neurasthenia. 

The  tonics  should  in  most  cases  be  continued  two  or  three  months  after  the  pa- 
tient leaves  the  bed.  The  bowels  must  be  regulated  by  laxatives  so  there  will  be 
no  straining.  Heavy  lifting  must  be  avoided.  Sexual  intercourse  should  be  post- 
poned for  at  least  one  month  after  the  patient  is  up  and  about. 


Hegar's  Operation. 

In  this  operation,  sometimes  called  the  Simon-Hegar  operation,  the  lower  part 
of  the  area  of  denudation,  including  the  perineal  and  rectal  wounds,  is  the  same 
as  in  Emmet's  operation,  and  is  sutured  in  about  the  same  way.  The  upper  part 
is  different  in  that  it  extends  up  the  center  of  the  posterior  vaginal  wall  (Fig.  512) 
instead  of  up  each  lateral  sulcus.  This  gives,  within  the  vagina,  simply  a  trian- 
gular area  of  denudation,  with  the  apex  lying  high  up  on  the  posterior  vaginal  wall. 

This  area  of  denudation  may  be 
closed  by  sutures  which  pass  from  side 
to  side  of  the  triangle.  The  first  su- 
ture is  passed  near  the  apex  and  the 
next  one  a  third  of  an  inch  below  and 
so  on  down,  practically  the  same  as  in 
suturing  a  sulcus  in  the  Emmet  opera- 
tion (Fig.  506-A),  until  all  the  sutures 
are  passed.  The  sutures  are  then  tied, 
closing  the  vaginal  portion  of  the 
wound. 

In  place  of  the  single  row  of  inter- 
rupted sutures,  it  is  preferable  to  ap- 
proximate the  deep  tissues  by  buried 
sutures  and  then  close  the  superficial 
portion  by  another  row,  as  shown  in 
P'igs.  513  and  514.  Both  the  deep  su- 
/ig.  512.    Hegar's  Operation.    Showing  the  tures  and  Superficial  suturcs  may  be 

outline  of  the  area  of  Denudation,  and  also   tlie  interrupted  Or  COntiuUOUS,  aS  prcfeiTed. 

method  of   removing  strips  of  niiicosa  with  llie  xj  >  •  • 

scissors.    (Vryiit-dynecoiogy.)  Hcgar  s  Operation    IS    morc  simple 


STEPS  IN   HEGAR'S  OPERATION 


497 


than  Emmet's  and  can  be  completed  more  qu^(•kl)^  When  the  denudation  is 
extended  well  out  to  the  sides  and  some  deep  excision  of  tissue  is  made,  as 
(lescnbed  under  the  Emmet  operation  (Fig.  504),  the  Hegar  operation  gives  a 
good  result.     Its  principal  effects  are: 

a.  It  removes  the  excess  of  posterior  vaginal  wall  which,  in  the  form  of  colpocele 


Fig.  513.  Hegar's  Operation.  Showing  the  method  of  bringing  to- 
gether the  tissues  by  Buried  Sutures.  (Doderleia  and  Kronig— Opera- 
fire  Gynakologie.) 


or  rectocele,  projects  from  the  orifice  and  when  marked   tends  to  drag  down  the 
cervix  uteri. 

b.  It  brings  together  in  the  median  the  lateral  pelvic  tissues  about  the  lower  part 
of  the  vagina.  These  are  brought  together  between  the  rectum  and  vagina. 
Now  some  of  these  tissues  normally  lie  between  the  rectum  and  vagina,  but  most 


498 


LACERATIONS  AND  FISTULiE 


of  them  pass  back  of  the  rectum  (Figs.  489,  493).  In  bringing  them  together 
between  the  rectum  and  vagina  the  operation  does  not  make  an  anatomical  restora- 
tion of  the  pelvic  sling,  but  it  does  to  a  large  extent  make  a  physiological  restora- 
tion of  the  sling,  in  that  the  sling  is  shortened  by  this  approximation  of  its  sides 
between  the  rectum  and  vagina,  and  the  slack  is  thus  taken  up.   The  line  of  support 


Fi(?.  514.  Hegar's  Operation.  Showing  the  closure  of  the  sup- 
erficial i^ortion  of  the  vaginal  wound  by  interupted  .sutures.  A 
continuous  suture  maybe  ti.sed  if  preferred.  (Doderlein  and  Kronig 
—  Operative  Clynakologie.) 


in  the  pelvic  floor  then  runs  between  the  rectum  and  vagina  instead  of  back  of  the 
rectum  as  normally.  Wiien  the  shortening  is  sufhcient,  good  support  is  secured, 
with  consequent  relief  of  the  distressing  symptoms. 

Tills  drawing  together  of  hileral  tissues  between  tiie  rectum  and  vagina  at  the 
anterior  part  of  the  pelvic  sling,  and  tluur  union  there  by  scar-tissue,  takes  place 


THK  TAIT  OPERATION 


499 


to  a  greater  or  less  extent  in  pnictically  all  operations  for  the  restoration  of  the 
pelvic  floor — in  Emmet's,  Hegar's,  Tait's  and  the  various  modifications  of  each— 
and  the  careful  bringing  together  of  these  deep  lateral  tissues  by  buried  sutures 
is  an  important  step  in  each  of  the  operations. 


Tait's  Operation. 

This  is  commonly  known  as  the  "flap-splitting"  operation. 
Siinger-Tait  operation. 


It  is  called  also  the 


Fig.  515.  Tait's  Operation.  The  Line  of  Incision  for 
Ordinary  Laceration  of  the  pelvic  floor.  (Thomas  and  Mnade 
— Diseases  of  Women.) 


An  incision  is  made  along  the  lower  margin  of  the  area  to  be  denuded,  as  show'n 
in  Fig.  515,  and  the  mucous  membrane  is  raised  as  a  flap,  as  shown  in  Fig.  518. 

The  area  of  denudation  is  nearly  the  same  as  in  Hegar's  operation  l>ut  it  has  over 
it  a  large  flap.     This  flap  is  both  an  advantage  and  a  disadvantage. 


500 


LACERATIONS  AND  FISTULA 


One  advantage  is  that  it  acts  as  a  roof  to  protect  the  repaired  area  from  the 
secretions  from  above  which,  in  the  other  forms  of  operation,  sometimes  infect  the 
wound  and  cause  partial  or  complete  failure.  Furthermore,  the  flap-method  gives  a 
large  raw  surface  for  approximation  without  any  loss  of  tissue,  and  the  amount  of 
tissue  left  in  the  flap  adds  somewhat  to  the  mass  which  fills  the  weak  place  in  the 
pelvic  floor. 

A  distinct  disadvantage  of  the  flap  is  that  it  may  prevent  free  access  to  the  upper 


Fig.  516.  Tail's  Operation.  The  Line  of  Incision  for 
Laceration  into  the  Rectum.  The  short  incision  extending 
downward  from  each  corner  of  the  regular  incision  is  for  tho  pur- 
pose of  exposing  the  torn  and  retracted  ends  of  the  sphincter  ani 
muscle.      (Thomas  and  Kunde— Diseases  of  Women.) 


parts  of  the  wounds.     When  the  laceration  extends  very  high,  the  deepe?  parts 
can  not  be  so  easily  denuded  nor  sutured  to  the  best  advantage. 

This  operation  is  especially  ai)plicable  in  those  cases  where  it  is  important  to 
avoid  loss  of  tissue,  particularly  in  cases  of  laceration  into  the  rectum  that  have 
resisted  one  or  two  previous  operations.  Iji  some  such  cases,  there  is  so  much  scar- 
tissue  and  apparently  so  much  loss  of  tissue  that  approximation  over  a  wide  area 
by  ordinary  denudation  fan  not  be  secured  without  injurious  tension.     In  such  a 


STEPS  IN     TAIT'S  OPERATION 


501 


case  the  main  object  is  to  secure  union  of  the  sphincter  muscle  and  the  rectal  wall, 
and  this  is  more  certain  of  attainment  by  the  Tait  operation,  because  approximation 
over  a  large  area  is  secured  without  loss  of  tissue  and  without  injurious  tension 
and  also  because  the  united  surfaces  are  better  protected  from  vaginal  and  rectal 
fluids. 

The  special  steps  in  the  operation  are  as  follows: 

1.  Making  the  Incision,  from  which  the  flap  may  be  raised.    For  the  ordinary 


Fig.  517.     Tait's  Operation.     Making  the  Incision  with  » 

Scissors.      (Reed —  Text -book  of  Gynecology.) 

laceration,  the  incision  has  the  outline  shown  in  Fig.  515.  When  the  laceration 
extends  through  the  sphincter  ani,  special  short  incisions  are  made  on  one  each  side, 
extending  from  the  lateral  part  of  the  main  incision  downward  over  the  dimples 
formed  by  the  retracted  ends  of  the  torn  sphincter,  as  shown  in  Fig.  516.  The  inci- 
sion for  raising  the  flap  may  be  conveniently  made  with  scissors,  as  shown  in 
Fig.  517. 

2.  Raising  the  Flap.  After  making  the  incision  (Fig.  517),  dissection  is  made 
up  the  recto-vaginal  septum  and  also  out  into  the  lateral  tissues,  so  that  a  flap  is 
raised  as  shown  in  Fig.  518.  When  the  tear  extends  into  the  rectum,  the  dissection 
is  made  so  that  the  rectal  portion  of  the  wound  also  forms  a  flap  that  may  be  turned 
down  and  folded  somewhat  and  sutured,  uniting  the  torn  ends  of  the  sphincter  and 
closing  the  tear  in  the  rectal  wall. 


502 


LACERATIONS  AND  FISTULA 


3.  Suturing.  This  does  not  differ  essentially  from  the  suturing  in  the  other 
operations.  It  was  formerly  the  custom  to  suture  only  from  the  perineal  surface, 
the  silkwoim-gut  sutures  being  passed  deeply  as  in  closing  the  perineal  portion  of 


I'i)?.  518.  Tail'.-  Oj^eiation.  Bringing  tno  deeip  tis?ue> 
together  by  Buried  Sutures.  The  flap  i.s  raised  out 
of  the  way.  (DOderiein  and  '  Kronif; — Operative 
dlinakologie.) 


Fig.  519.  Tait's  Operation.  The  deep  tissue.-^  lia\e 
been  approximated  by  Buried  Sutures.  The  Redun- 
dant portions  of  the  Flap  are  being  cut  away.  (Doder- 
lein  and  Kromg— Operative  Gynakologie.) 


the  wound  in  i^mmet's  and  Hegar's  operations.  Tlie  operation  is  much  ■  more 
effective,  however,  when  the  deep  lateral  ti.^.sues  :ire  fir.st  l)rought  together  by  buried 
sutures,  us  showii  iu  Fig.  518.     The  perineal  portion  is  tiicn  closed  in  the  usual  way 


STEPS  IN  TAIT'S  OPERATION 


503 


by  interrupted  silkworm-gut  sutures,  passed  well  out  to  the  sides  and  very  deeply,  so 
as  to  bring  the  lateral  tissues  from  each  side  firmly  together  in  the  median  below 
the  restored  vagina. 


Fig.  520.  Tait's  Operation.  Showing  the  deej 
and  superficial  sutures.  The  redundant  portions  of 
the  flap  have  been  removed.  Continuous  sutures 
may  be  used  if  preferred.  (Doderlein  and  Kronig 
—Operative  Gynakologie.) 


Fig.  521.  Tait's  Operation.  Showing  the  line  of  ap- 
proximation on  the  perineum  and  in  the  vagina.  All 
vaginal  sutures  and  all  buried  sutures  are  of  catgut. 
The  perineal  sutures  are  preferably  of  silkworm-gut. 
(Doderlein  and  Kronig— Operaiire  Gynakologie.) 


There  is  usually  more  or  less  excess  of  flap— consequently  it  is  removed,  as  shown 
in  Fig.  519,  and  the  anterior  edges  of  the  flap  are  united  by  catgut,  as  indicated 
in  Figs.  520  and  521. 


504  LACERATIONS  AND  FISTULA 

Other  Operations. 

There  are  several  other  operations  for  the  repair  of  the  pelvic  floor,  most  of  them 
being  modifications  of  Emmet's  or  Hegar's  or  Tait's  operation,  the  lines  of  denu- 
dation and  of  suturing  varying  in  each  case  to  suit  the  operator. 

There  is  one  operation,  however,  essentially  different  from  those  previously 
described,  and  that  is  the  operation  carried  out  by  Harris.  In  this,  the  levator 
ani  muscle  itself  is  exposed  by  dissection  and  the  torn  ends  and  the  scar-tissue  hdng 
be  ween  them,  are  excised.  The  separated  ends  of  the  muscle  are  then  brought 
together  by  sutures  and  the  vaginal  mucosa  is  closed  over  them.  On  paper  this 
operation  is  the  ideal  one,  but  in  the  actual  application  to  the  conditions  found  in 
the  pelvis  in  these  cases,  its  adA'antages  are  not  so  apparent.  In  the  severe  cases 
there  is  scar-tissue  extending  all  through  the  damaged  area  about  the  torn  ends 
of  the  muscle,  and  this  interferes  with  their  smooth  dissection  and  clean  exposure. 
Under  these  circumstances  the  accurate  isolation  of  the  levator  ani  muscles,  as 
contemplated,  requires  so  much  dissection  and  handling  of  the  deep  tissues  that  it 
adds  considerably  to  the  severity  of  the  operation  and  the  length  of  anesthesia 
required.  I  think  the  "deep  excision  of  tissue"  from  the  sides  of  the  pelvis,  as 
explained  in  Fig.  504,  is  decidedly  preferable.  By  it,  a  sufficient  amount  of  tissue 
may  be  quickly  excised  from  the  damaged  areas  in  the  pelvic  sling  to  give  the 
required  shortening  and  support  when  the  sutures  are  tied. 

COLPOCELE,  RECTOCELE,  CYSTOCELE. 

In  man}"  cases  of  laceration  of  the  pelvic  floor,  there  is  considerable  protrusion 
of  the  vaginal  walls,  constituting  colpocele.  It  may  be  the  posterior  vaginal  wall 
(posterior  colpocele — Figs.  239)  or  it  may  be  the  anterior  vaginal  (anterior 
colpocele). 

If  the  rectal  wall  follows  the  prolapsing  posterior  vaginal  wall,  the  condition 
is  called  rectocele  (Figs.  240,  241,  244,  245,  246).     Rectocele  is,  of  course,  corrected' 
by  the  regular  repair  of  the  pelvic  floor. 

If  the  bladder  follows  the  prolapsing  anterior  vaginal  wall,  the  condition  is  called 
cystocele  (Figs.  240,  241,  242,  243).  Cystocele,  when  present,  requires  a  special 
operative  measure  for  its  cure,  hence  it  is  necessary  to  give  it  some  particular  con- 
sideration. 

Operation  for  Cystocele. 

When  decided  prolapse  of  the  anterior  vaginal  wall  and  base  of  the  bladder  is 
present,  that  should  ordinarily  be  taken  care  of  at  the  same  time  that  the  posterior 
portion  of  the  pelvic  floor  is  repaired.  The  operative  measure  for  the  correction 
of  this  condition  is  designated  as  "anterior  colporrhaphy "  and  also  as  "cystocele 
operation."  It  is  carried  out  just  previous  to  the  denudation  for  the  regular  re- 
pair of  the  pelvic  floor. 

Hegar's  operation  for  cystocele.  The  redundant  vaginal  wall  is  removed  o^'er  a 
large  elliptir-al  area.  This  denudation  may  bo  made  by  clipping  off  strips  with  the 
scissors  as  ex])laine(l  when  speaking  of  denudation  of  the  posterior  wall  (Figs.  502, 
503,  512)  or  the  muco.sa  of  each  side  may  be  raised  as  a  flap  and  then  cut  off  as 


HEGAR'S  OPERATION  FOR  CYSTOCELE 


505 


indicated  in  Fig.  522.  The  denudation  should  be  wide,  so  that  when  the  sides  of 
the  elUpse  are  brought  together  there  will  be  some  tension  laterally,  that  a  firm 
support  from  side  to  side  may  be  formed  under  the  base  of  the  bladder. 

The  deeper  portions  of  the  area  are  closed  by  buried  sutures  and  then  the  nuicosa 
by  superficial  sutures,  as  indicated  in  Fig.  523.     The  sutures  are  all  of   catgut  and 


Fig.  522.  Hegar's  Operation  for  Cystocele.  The  va- 
ginal mucosa  raised  and  the  redundant  portions  being 
excised.  This  shows  also  the  area  of  Denudation.  (Doder- 
lein  and  Kronig — Operative  Gynakologie.) 


Fi^.  523.  Hegar's  Operation  for  Cystocele.  Showing 
the  method  of  closing  by  deep  and  superficial  sutures. 
Continuous  sutures  may  be  used  for  both  deep  and 
superficial  if  preferred.  (Doderlein  and  Kronig— 0;;era- 
tive  Gynakologie.) 


may  be  made  interrupted  or  continuous.     The  latter  are   preferable,  as  they  save 
time. 

In  the  Hegar  operation  the  lines  of  tension  extend  exclusively  from  side 
to  side.  There  is  no  downward  pull  on  the  cervix,  which  is  a  serious  disadvan- 
tage of  the  Stoltz  operation  ("purse-string' '  operation.) 


506 


LACERATIONS  AND  FISTULA 


RECTO=VAQINAL  FISTULA. 

From  injuries  in  labor  or  from  destructive  ulceration  or  from  other  causes,  fis- 
tulous openings  may  form,  extending  in  various  directions.  The  different  varieties 
of  genital  fistulae,  with  the  name  given  to  each,  are  shown  in  Fig.  524. 

A  recto=yaginal  fistula  is  an  opening  from  the  rectum  into  the  vagina.  The  size 
of  the  fistula  may  vary  from  a  small  tortuous  tract,  admitting  only  a  small  probe 
and  permitting  only  gas  or  fluid  to  escape,  to  a  large  opening,  involving  a  large 
part  of  the  recto-vaginal  septum,  and  through  which  passes  practically  all  the 
rectal  contents. 


Fig.  524.  Fistulae  of  tlie  Genital  Tract.  1.  Urethro-vaginal  fistula.  2.  Vesico- 
vaginal fistula.  3.  Recto-vaginal  fistula.  4.  Vesico-uterine  fistula.  5.  Uretero-vaginal 
fistula.     6.  Intestino-vaginal  fistula.     (.G'lWiam— Practical  G)jnecolo«jy.) 


Etiology  and  Pathology. 

The  following  are  the  causes  of  recto-vaginal  fistulae. 

1.  Injuries  in  labor,  in  rare  cases  a  hole  may  be  torn  through  the  recto-vaginal 
septum,  resulting  dii-cctly  in  a  fistula.  Usually,  however,  a  fistula  resulting  from 
labor,  is  due  to  a  complete  laceration  of  the  perineum,  which  is  repaired  at  once  or 


RECTO- VAGINAL  FISTULA  507 

later,  but  fails  to  heal  entirely.  The  lower  part  of  the  approximated  surfaces 
unite,  but  a  small  part  of  the  upper  angle  fails  to  heal,  and  the  result  is  a  fistula 
extending  from  the  rectum  into  the  vagina. 

2.  Chronic  ulceration  of  the  posterior  vaginal  wall,  which  may  be  chancroidal 
or  syphilitic  or  tubercular.     It  usually  affects  the  lower  part  of  the  vagina. 

3.  Stricture  of  the  rectum,  with  dilatation  and  ulceration  of  the  rectal  wall  above 
it. 

4.  Malignant  disease  of  the  recto-vaginal  septum.  This  is  usually  secondary 
to  cancer  of  the  cervix  uteri  or  cancer  of  the  rectum. 

5.  Operation.  A  pelvic  abscess  which  has  ruptured  into  the  rectum,  will,  if 
opened  into  from  the  vagina,  give  a  rerto-vaginal  fistula.  Again,  in  stricture  of 
the  rectum,  there  niay  be  dilatation  anrl  ulceration  of  the  rectal  wall  above  the 
stricture  with  peri-rectal  inflammation  and  an  abscess.  8uch  an  abscess,  if  opened 
into  from  the  vagina,  will  give  a  recto-vaginal  fistula.  Again,  the  rectal  wall  may 
be  injured  directly  in  various  operations. 

Diagnosis. 

The  diagnostic  symptoms  of  recto-vaginal  fistula,  are  the  escape  of  some  of  the 
rectal  contents  into  the  vagina  and  the  vaginal  irritation  caused  by  the  same. 
The  amount  and  character  of  the  leakage  from  the  rectum  varies  much  in  different 
cases.  In  the  smallest  fistulae,  only  gas  with  occasionally  some  liquid,  passes. 
With  the  opening  a  little  larger,  there  may  be  free  leakage  only  when  the  bowels 
are  loose  and  the  contents  fluid.  In  still  other  cases,  nearly  all  the  rectal  contents, 
whether  fluid  or  solid,  pass  through  the  fistulous  opening. 

Digital  examination  reveals  a  rough  place  in  the  posterior  vaginal  wall.  If  the 
opening  is  small,  only  a  small  elevation  or  depression  or  a  rough  place,  is  felt. 
On  inspection,  if  the  opening  is  large  it  may  be  seen,  but  if  small  only  a  rough 
place  with  a  small  slit  is  visible.  Very  often  a  reel  papule  marks  the  vaginal  open- 
ing of  the  fistula.  Exploration  of  the  opening  with  a  probe,  with  a  finger  of  the 
other  hand  in  the  rectum,  shows  that  the  sinus  communicates  with  the  rectum. 
In  a  doubtful  case  in  which  the  opening  cannot  be  found  or  in  which  a  probe  cannot 
l3e  introduced,  the  fact  that  there  is  a  recto-vaginal  fistula  may  be  established  and 
its  location  determined  by  injecting  colored  water  (methylene  blue,  ^%  solution") 
into  the  rectum  and  watching  for  its  appearance  on  the  posterior  vaginal  wall. 
If  there  is  syphilitic  or  chancroidal  or  tubercular  ulceration,  or  if  there  is  a  stricture 
of  the  rectum  or  malignant  disease,  the  evidences  of  the  complicating  disease  will 
be  present,  in  addition  to  the  evidences  of  fistula. 

Treatment. 

In  the  recto-vaginal  fistula  following  labor,  that  is,  where  part  of  the  repaired 
recto-vaginal  septum  failed  to  heal,  no  secondary  operation  should  be  undertaken 
for  the  closure  of  the  fistula  for  six  or  eight  weeks  after  labor.  The  fistula  may  close 
spontaneously  within  a  few  weeks.  Again,  an  operation  in  the  genital  tract  in  the 
puerperium  increases  the  chance  of  puerperal  sepsis.  Also,  the  patient  is  later  in 
much  better  condi-tio-n  generally  for  the  operation,  as  she  has  recovered  from  the 


508  LACERATIONS  AND  FISTULA 

debilitating  effects  of  parturition.  Locally,  also,  the  tissues  have  returned  to  their 
normal  condition,  and  complete  primary  union  is  much  more  certain  to  follow  the 
operation.  For  sometime  following  labor  the  uterine  discharge  would  tend  to 
interfere  with  healing  and  the  tissues  are  so  friable  that  the  sutures  are  much  more 
liable  to  cut  through. 

Palliative  treatment.  In  the  meantime,  the  vagina  must  be  kept  clean  by  anti- 
septic vaginal  douches,  once,  twice  or  three  times  daily,  as  indicated  by  the  amount 
of  leakage  through  the  opening.  If  the  opening  is  very  small,  stimulation  by  touch- 
ing it  occationally  with  silver  nitrate  stick  or  with  carbolic  acid,  will  sometimes 
cause  the  fistula  to  close.  If  the  fistula  persists  after  thorough  recovery  from  the 
parturition,  it  may  be  closed  by  operation. 

Operation. 

In  the  simple  form  of  fistula,  without  complicating  ulceration  or  infiltration,  the 
operation  for  closure  may  be  undertaken  without  special  local  preparatory  treat- 
ment. 

The  preparation  of  the  patient,  operator,  instruments  and  dressings  are  the  same 
as  for  repair  of  complete  laceration  of  the  pelvic  floor. 

Steps.  The  patient  is  placed  in  the  dorsal  posture  and  the  fistula  exposed  by 
retractors  or  by  the  fingers  of  an  assistant  as  is  found  most  convenient.  The  sphinc- 
ter ani  muscle  should  be  temporarily  paralyzed  by  stretching  before  beginning  the 
operation  proper. 

The  vicinity  of  the  fistula  is  then  denuded  as  shown  in  Fig.  526.  The  denu- 
dation may  be  made  with  scissors  or  knife,  as  found  most  convenient.  This 
removes  all  scar  tissue  along  the  fistulous  tract  and  gives  healthy  denuded  tissue 
for  approximation.  A  large  area  should  be  denuded  on  the  vaginal  surface,  and 
this  as  it  goes  deeper  should  slant  gradually  toward  the  point  at  which  the  fistula 
enters  the  rectum. 

The  opening  in  the  rectum  should  not  be  made  larger  than  is  absolutely  necessary 
to  remove  the  hard  scar-tissue  from  the  opening  and  to  denude  the  edges  of  the 
rectal  mucosa,  so  that  when  these  edges  are  brought  together  union  will  take  place. 

The  sutures  are  passed  as  in  Fig.  525.  The  needle  enters  the  vaginal  mucosa 
a  short  distance  outside  the  area  of  denudation,  passes  to  the  bottom  of  the  wound, 
is  brought  out  in  the  denuded  edge  of  the  rectal  mucous  membrane,  enters  at  a 
corresponding  point  on  the  opposite  side  and  emerges  from  the  vaginal  mucosa. 
When  this  suture  is  tied  it  approximates  the  denuded  area  in  the  entire  thickness 
of  the  vaginal  wall  and  also  the  denuded  edge  of  the  rectal  mucosa,  but  the  suture 
does  not  touch  the  free  surfa(!e  of  the  rectal  mucosa.  It  is  important 
that  the  suture  should  not  penertate  to  the  interior  of  the  rectimi  as  the  rectal 
contents  might  cause  inflammation  along  its  tract.  The  sutures  are  placed  about 
one-fourth  of  an  inch  apart,  and  in  such  a  way  that  when  tied,  the  line  of  approxi- 
mation lies  in  the  long  axis  of  the  vagina.  If  desired,  the  deeper  portions  of  the 
wound  may  be  closed  with  buried  catgut  sutures,  as  explained  under  vesico-vaginal 
fistula  (Fig.  526).  A  wider  surface  for  approximation  may  be  secured,  without 
loss  of  tissue,  by  splitting  the  edges  of  the  opening  and  approximating  the  raw 
surface  of  the  rectal  flaps  by  buried  catgut,  and  approximating  the  raw  surface  of 


TREATMENT  OF  RECTO-VAGINAL  FISTULA  509 

the  vaginal  flaps  by  catgut  or  silkworm-gut.  In  the  fistula  with  a  small  rectal 
opening  the  above  is  the  method  of  suturing  to  be  employed. 

When  there  is  a  large  opening  into  the  rectum,  it  may  be  necessary  to  close  the 
opening  in  the  rectal  mucosa  with  a  separate  row  of  sutures  passed  from  the  recta! 
surface  and  tied  in  the  rectum.  In  order  to  do  this,  it  is  necessary  to  dilate  the 
sphincter  ani  widely  so  that  the  rectal  end  of  the  fistula  may  be  reached  for  suturing. 
The  denudation  is  made  the  same  as  previously  described.  The  rectal  sutures 
include  only  the  rectal  mucosa  and  a  small  amount  of  submucous  tissue.  After 
the  opening  in  the  rectal  mucosa  has  been  closed  the  remainder  of  the  wound  is 
closed  by  sutures  from  the  vaginal  surface  as  already  described. 

In  a  case  of  large  fistulous  opening  near  the  anus,  better  approximation  can 
be  secured  by  dividing  the  tissues  between  the  fistula  and  the  anus,  thus  convert- 
ing the  fistula  into  a  complete  laceration  of  the  perineum,  which  is  then  repaired 
in  the  ordinary  way. 

The  after=treatment.  The  after-treatment  of  a  case  of  recto-vaginal  fistula  is 
the  same  as  after  repair  of  complete  laceration  of  the  pelvic  floor. 

Special  measures.  In  some  cases  there  has  been  so  much  loss  of  tissue  that  the 
sides  of  the  opening  cannot  be  satisfactorily  approximated.  This  marked  loss  of 
tissue  may  be  due  to  extensive  ulceration  at  the  time  the  fistula  was  formed,  or  to 
repeated  attempts  at  repair.  In  either  case  the  vicinity  of  the  opening  is  occupied 
by  scar-tissue,  extending  in  various  directions  and  making  the  parts  so  rigid  that 
the  opening  cannot  be  satisfactorily  closed  except  by  the  employment  of  one  of  the 
following  special  measures. 

1.  Incisions  of  the  vaginal  mucous  membrane  some  distance  from  the  opening, 
to  permit  the  mucosa  being  drawn  over  the  opening  without  injurious  tension. 
Each  of  these  incisions,  if  made  short,  may  be  closed  immediately  by  passing  a 
suture  in  the  long  axis  of  the  incision. 

2.  Transplantation  of  a  flap  of  vaginal  mucous  membrane,  the  flap  to  receive 
its  nourishment  through  an  unsevered  portion  at  one  or  both  ends. 

3.  Detachment  of  the  rectum  from  the  fixed  vagina,  by  incision  in  the  perineum, 
and  closure  of  the  rectal  wall  independently  of  the  vaginal  wall.  In  certain  cases 
of  large  recto-vaginal  opening,  the  vaginal  wall  is  bound  immovably  by  scar- 
tissue  and  the  sides  of  the  rectal  opening,  are  likewise  held  apart  by  their  attach- 
ment to  the  vaginal  wall.  If  a  transverse  incision  be  made  in  the  perineum  and 
the  rectal  wall  dissected  from  the  vaginal  to  a  considerable  distance  above  the 
fistula,  it  then  becomes  freely  movable  and  the  sides  of  the  opening  may  be  approx- 
imated. They  should  be  united  by  one  or  two  rows  of  sutures.  The  sutures  may 
be  passed  from  the  opening  in  the  vaginal  wall  or  from  the  perineal  wound,  as  found 
most  convenient. 

If  the  fistula  is  complicated  by  ulceration,  the  ulceration,  of  whatever  character, 
should  be  healed  as  far  as  possible  before  the  attempt  is  made  to  close  the  fistula. 
In  some  of  these  cases,  the  patient  has  tertiary  syhpilis  and  needs  a  prolonged  course 
of  treatment  for  the  ulceration  and  for  the  syphilitic  deposit,  and  also  for  the  marked 
anemia  and  generally  lowered  vitality  that  accompanies  that  disease. 

In  the  syphilitic  cases,  if  closure  is  attempted  while  the  ulceration  is  still  present 
or  while  the  patient  is  anemic  and  weak  from  ulceration  elsewhere,  the  operation 


510  LACERATIONS  AND  FISTULA 

is  very  liable  to  result  in  failure  and  the  last  opening  may  be  larger  than  the  first. 
In  a  tubercular  fistula  and  in  a  malignant  fistula,  it  is  useless  to  attempt  closure 
of  the  fistula  unless  the  infiltrated  area  can  be  excised  and  healthy  tissue  approx- 
imated hj  the  sutures. 

Other  Fecal  Fistulae. 

Occasionally  there  occur  other  varieties  of  fecal  fistula,  opening  into  the  genital 
tract.  There  may  be  an  opening  into  the  vagina  from  the  sigmoid  flexure  or  from 
the  colon  or  from  the  small  intestine.  There  may  be  an  opening  into  the  uterus 
from  the  sigmoid  or  from  the  colon  or  from  the  small  intestine. 

The  most  common  form  is  that  following  some  operation  at  the  vaginal  vault, 
particularly  vaginal  hysterectomy.  It  appears  in  the  form  of  a  small  opening 
in  the  scar  at  the  vaginal  vault,  from  which  intestinal  gas  or  fluid  escapes.  It  is 
caused  by  injury  of  the  intestine  during  operation  or  by  ulceration  of  the  intestinal 
wall  before  or  after  operation.  The  injury  may  be  caused  by  a  bite  of  the  bowel 
by  the  tip  of  the  pressure-forceps,by  a  puncture  of  the  bowel  by  a  needle  or  ligature- 
carrier,  by  inclusion  of  a  small  portion  of  the  bowel  in  a  ligature  as  it  is  being  tied 
or  by  partial  or  complete  rupture  of  the  bowel  in  breaking  up  adhesions.  Some- 
times a  tubal  abscess  is  discharging  into  the  large  or  small  intestine  and, 
when  such  an  abscess  cavity  is  opened  by  vaginal  incision,  a  fecal  fistula  results. 

Fecal  fistulae  involving  the  vault  of  the  vagina  often  close  spontaneously  after 
a  few  weeks,  the  vagina  in  the  meantime  being  kept  clean  by  antiseptic  douches. 

If  the  fistula  persists  after  several  weeks  with  no  apparent  prospect  of  closing  it 
will  be  necessary  to  close  it  by  an  operation  involving  abdominal  section  or  vaginal 
section.  The  character  of  the  operation  required  will  depend  on  the  character  of 
the  fistula.  It  should  be  undertaken  only  by  one  skilled  in  pelvic  surgery,  for 
conditions  very  difficult  to  handle  may  be  encountered. 

The  other  forms  of  genito-intestinal  fistula  are  rare,  so  rare  that  they  are  curi- 
osities. They  are  due  to  special  causes  and  require  special  treatment,  usually 
involving  abdominal  section. 


VESICO=VAGINAL  FISTULA. 

There  may  bo  an  opening  between  the  genital  tract  and  the  urinary  tract  at  one  of 
several  situations  (Fig.  524).     The  location  is  indicated  by  the  name   as  follows: 

Urethro-\-aginal  fistula — between  urethra  and  vagina. 
A'esico-vaginal  fistula — between  bladder  and  vagina. 
Uretero-vaginal  fistula — between  ureter  and  vagina. 
Vesico-uterine  fistula — -between  bladder  and  uterus. 
Uretero-uterine  fistula — between  ureter  and  uterus. 

All  of  these  fistulae  are  rare,  the  most  common  being  the  vesico- vaginal.  A 
vesico=vaginal  fistula  is  an  opening  from  the  bladder  into  the  vagina.  The  size 
of  the  fistula  may  vary  from  a  small  opening,  permitting  only  slight  leakage,  to 
a  large  opening  through  which  all  the  urine  passes. 


VESICO- VAGINAL   FISTULA  511 

Etiology. 

The  following  are  the  causes  of  the  vosico- vaginal  fistula: 

1.  Injuries  in  labor.  In  prolonged  labor  where  the  lower  portion  of  the  bladder 
is  caught  and  held  for  several  hours  between  the  head  and  the  pubic  bone,  sloughing 
may  follow.  Part  of  the  base  of  the  bladder  and  the  anterior  vaginal  wall  are 
bruised,  the  circulation  is  more  or  less  cut  off,  the  parts  become  gangrenous  and 
after  a  few  days  the  slough  separates,  lea\'ing  a  vesico-vaginal  opening  through 
which  the  urine  passes.  Such  injuries  are  rare  in  recent  years  on  account  of  the 
gTeat  improvement  in  obstetric  teaching  and  practice.  Now,  the  head  is  not 
permitted  to  remain  for  several  hours  in  such  a  position  that  it  makes  serious  pres- 
sure on  the  bladder.  If  the  head  does  not  advance  satisfactorily  within  a  reason- 
able time  after  the  rupture  of  the  membranes,  the  child  is  delivered  by  forceps  or 
otherwise. 

A  still  rarer  form  of  damage  to  the  bladder  in  labor  is  that  in  which  the  bladder  is 
torn  directly,  either  by  the  manipulations  incident  to  a  version  or  by  the  forceps. 
In  that  case  the  dribbling  of  urine  is  noticed  immediately,  or  within  a  few  hours 
after  labor,  whereas  if  the  fistula  is  due  to  sloughing,  there  is  no  escape  of  urine 
until  the  separation  of  the  slough,  which  requires  several  days. 

2.  Chronic  ulceration  of  the  anterior  vaginal  wall  or  the  base  of  the  bladder. 
The  ulceration  may  be  chancroidal,  syphilitic  or  tubercular. 

3.  Malignant  disease  of  the  vesico-vaginal  septum.  This  is  usualy  secondary 
to  cancer  of  the  cervix  uteri. 

4.  Operations.  One  of  the  methods  of  treating  severe  chronic  cystitis  is  to  make 
an  opening  from  the  vagina  into  the  base  of  the  bladder,  so  as  to  give  constant 
drainage  of  the  latter.  Such  an  opening  usualy  closes  spontaneously  a  short  time 
after  the  drainage  tube  is  removed.  It  may,  however,  fail  to  close  promptly 
after  its  usefulness  is  ended,  and  in  that  case  becomes  a  vesico-vaginal  fistula, 
reqmring  operation. 

Diagnosis. 

The  patient  complains  of  urine  coming  from  the  vagina  and  of  much  vaginal 
irritation.  In  some  cases  the  patient  complains  simply  that  she  cannot  control 
the  urine. 

Digital  examination  reveals  a  rough  place  on  the  anterior  vaginal  wall.  If  the 
opening  is  large  it  may  be  distinctly  made  out  with  the  finger.  If  the  opening  is 
small,  only  a  slight  elevation  or  depression  or  rough  place  may  be  felt.  Upon  in- 
spection, if  the  opening  is  large,  it  may  be  seen,  but  if  it  is  small,  only  a  rough  place 
with  a  small  slit  is  visible.  Very  often  a  red  papule  marks  the  vagnial  opening 
of  the  fistula.  Exploration  of  the  opening  with  a  probe,  with  a  sound  in  the  bladder, 
shows  that  the  sinus  communicates  with  the  bladder.  If  the  opening  be  watched 
a  few  minutes,  urine  may  be  seen  escaping  from  it.  If  the  diagnosis  is  doubtful 
sterile  methylene-blue  solution  may  be  injected  into  the  bladder  and  its  appearance 
watched  for  at  the  supposed  vaginal  opening  of  the  fistula.  There  is  a  rare  con- 
dition which  must  be  carefully  differentiated  from  vesico-vaginal  fistula,  namely, 
uretero-vaginal  fistula. 

When  the  vesico-vaginal  opening  is  large,  the  fact  that  it  communicates  with  the 


512  LACERATIONS  AND  FISTULA 

bladder  is  apparent,  and  frequently  the  margins  of  the  opening  and  the  adjacent 
surfaces  of  the  vaginal  mucosa  and  vesical  mucosa  are  encrusted  with  the  phos- 
phates from  the  decomposed  urine.  In  one  of  my  cases  there  was  a  large  phos- 
phate stone  nearly  filling  the  contracted  bladder  and  projecting  through  the  large 
vesico-vaginal  opening  into  the  vagina. 

The  irritation  caused  by  the  decomposition  of  urine  in  the  vagina  is  very  gi-eat, 
and  the  constant  odor  of  decomposing  urine  combined  with  the  constant  leakage 
of  fluid,  soaking  pads  and  clothing,  makes  the  patient's  very  existence  a  burden 
to  her. 

Treatment. 

If  the  fistula  is  due  to  malignant  disease,  no  attempt  should  be  made  to  close  it 
unless  the  malignant  infiltration  is  so  situated  that  it  can  be  completely  extirpated. 
In  the  inoperable  cases,  local  cleanliness  and  local  sedatives  are  indicated. 

If  the  fistula  has  resulted  from  sloughing  after  labor,  it  is  best  to  postpone  the 
operation  for  repair  for  at  least  eight  weeks,  until  the  patient  has  fully  recovered 
from  parturition  and  the  tissues  have  become  strong  enough  to  hold  the  sutures 
well.     During  the  time  the  patient  is  waiting,  palliative  treatment  will  be  necessary. 

Palliative  Treatment.,  This  consists  in  keeping  the  parts  clean  and  in  receiving 
and  disposing  of  the  urine,  so  that  it  does  not  come  in  contact  with  the  clothing. 
To  accomplish  the  first  object,  a  urinarj^  antiseptic  such  as  urotropin  should  be  given 
internally.  Also  a  vaginal  douche  of  borax  (a  tablespoonful  to  a  quart  of  water) 
or  a  weak  carbolic  douche  (  |%)  should  be  given  two  or  three  times  daily  and  the 
external  genitals  should  be  washed  frequently  with  a  carbolic  wash.  If  there  is 
much  vulvar  irritation,  the  measures  mentioned  under  acute  vulvitis  may  be  em- 
ployed. For  catching  the  urine  and  protecting  the  clothing,  one  of  the  urinals 
found  in  the  instrument-stores  may  be  used.  If  no  satisfactory  urinal  can  be 
obtained,  an  absorbent  cotton  pad  covered  with  a  large  piece  of  rubber-sheeting 
may  be  used.  The  piece  of  rubber-sheeting  is  held  in  place  by  a  suitable  bandage 
and  the  pad  is  changed  as  frequently  as  it  becomes  wet,  so  that  no  leakage  into  the 
clothing  takes  place.  All  the  surfaces  with  which  the  urine  comes  in  contact  may 
be  coated  twice  daily  with  benzoated  zinc-oxide  ointment. 

If  the  fistula  is  very  small,  cauterization  may  aid  spontaneous  closure.  The 
vaginal  portion  of  the  fistulous  tract  may  be  cocainized  and  then  touched  with  car- 
bolic acid  or  nitric  acid.  An  occasional  stimulation  with  the  silver  nitrate  stick  is 
sometimes  u.seful.  If  after  the  patient  has  recovered  from  parturition,  the  fistula 
shows  no  evidence  of  early  closing,  au  operation  is  indicated, 

Operation. 

In  an  operative  case  of  vesico-vaginal  fistula  the  preparatory  measures  are 
important.  The  object  is  to  secure  a  healthy  condition  of  the  edges  of  the  fistulous 
opening.  These  edges  are  often  inflamed  and  covered  with  phosphatic  deposits. 
These  deposits  should  be  removed  with  cotton  and  the  raw  surfaces  brushed  with 
silver  nitrate  solution  (2%  to  4%)  or  some  of  the  other  silver  preparations.  If 
the  deposits  adhere  to  the  mucous  membrane  and  are  difficult  to  remove,  they  may 
be  dissolved  by  the  application  of  a  weak  nitric  acid  solution  (one  or  two  drops  to 


TREATMENT  OF  VESICO- VAGINAL  FISTULA  51J 

the  ounce).  Frequent  hot  vaginal  douches  of  plain  water  or  borax  solution  or 
weak  carbolic  solution,  are  beneficial,  as  are  also  frequent  warm  sitz-baths.  After 
the  douches  and  sitz-baths  the  patient  should  dry  the  parts  as  best  she  can  and  then 
apply  the  zinc  oxide  ointment  over  all  the  surfaces,  to  prevent  contact  with  the 
urine. 

Every  second  or  third  day  the  physician  may  introduce  the  Sims  speculum, 
cleanse  the  parts  thoroughly,  apply  the  silver  preparation  and  then  coat  the  vaginal 
walls  and  adjacent  surfaces  with  benzoated  zinc-oxide  ointment  or  other  suitable 
protective. 

The  urine  may  be  made  more  acid  and  the  tendency  to  phosphatic  deposits  thus 
diminished,  by  giving  the  benzoic  acid  mixture  recommended  by  Emmet  (see  For- 
mulae). After  a  few  days,  when  the  uiine  is  strongly  acid  and  shows  but  little  ten- 
dency to  decomposition,  the  dose  of  the  benzoic  acid  mixture  may  be  reduced  from  a 
tablespoonful  to  a  teaspoonful,  as  the  larger  dose  may  produce  gastric  irritability. 
This  urinary  antiseptic  or  some  similar  one  should  be  continued  after  operation 
to  prevent  phosphatic  deposit  about  the  bladder  wound.  Also,  a  large  amount 
of  pure  water  should  be  given  to  keep  the  urine  will  diluted. 

The  same  general  preparation  of  the  patient  for  operation  should  be  carried  out 
as  for  repair  of  laceration  of  the  pelvic  floor.  Special  attention  must  be  given  the 
urine.  For  several  days  before  operation  the  patient  should  be  given  some  urinary 
antiseptic  every  six  or  eight  hours,  such  as  the  benzoic  acid  mixture,  just  mentioned, 
or  cystogen  or  urotropin  or  salol  and  boric  acid. 

A  specimen  of  urine  for  analysis  may  be  obtained  by  cleansing  the  vagina  and 
then  placing  a  bed-pan  under  the  patient  long  enough  to  collect  a  sufficient  quantity. 
Before  operation  it  must  be  determined  that  the  urethra  is  not  closed  by  shrink- 
age from  non-use  and  inflammatory  adhesions.  In  some  cases  no  urine  has  passed 
through  the  urethra  for  months  or  years.  If  the  urethra  is  not  of  proper  calibre 
it  should  be  dilated  during  the  preparatory  treatment. 

The  technique  of  the  operation  for  vesico-vaginal  fistulae  is  indissolubly  con- 
nected with  the  name  of  J.  Marion  Sims.  The  rise  of  Sims  to  great  prominence 
was  due  largely  to  his  admirable  work  in  these  cases.  Up  to  his  time  the  severer 
gi'ades  of  vesico-vaginal  fistula  weve  considered  incurable,  and  eveiy  such  patient 
was  consigned  to  life-long  misery  a  burden  to  herself  and  to  her  associates.  Ex- 
tensive vesico-vaginal  fistula  following  labor  was  much  more  common  then  than  it 
is  now,  for  obstetric  teaching  had  not  then  advanced  to  its  present  state.  Con- 
sequently there  were  many  patients  in  the  various  countries  of  the  world  suffering 
from  the  severer  forms  of  this  trouble,  and  all  were  practically  without  hope  of 
relief. 

Sims  took  hold  of  the  subject  and  perfected  the  means  for  exposing  the  fistula — 
Sim's  speculum  and  Sim's  posture — and  also  the  instruments  and  technique  for 
suturing  with  silver  wire.  He  also  provided  for  constant  drainage  of  the  bladder 
during  healing,  by  the  use  of  a  retention  catheter. 

These  improvements  together  with  his  tactile  skill,  his  painstaking  care  and  his 
courageous  perseverance,  enabled  him  to  obtain  results  that  were  before  considered 
impossible.  Apparently  hopeless  cases  were  made  well,  patients  were  restored 
from  a  miserable  existence  to  a  happy  life  and  eventually  the  fame  of  Sims  spread 


514  LACERATIONS  AND  FISTULA 

everywhere  in  the  civilized  world — and  history  justly  records  him  as  one  of  the 
great  leaders  in  medical  progress  and  one  of  the  great  benefactors  of  mankind. 
He  made  many  other  advances  in  the  treatment  of  diseases  of  women,  but  none 
so  striking  and  complete  as  in  vesico-vaginal  fistula.  The  silver  wire  sutures 
and  the  instruments  used  by  Sims  in  their  application,  still  hold  their  place  with 
some  operators,  though  most  operators  now  prefer  the  silkworm-gut  sutures  or 
buried  cat-gut  sutures.  In  some  cases  the  Sims  posture  and  the  Sims  speculum 
give  the  best  exposure  of  the  field  for  operation,  but  in  most  cases  the  operation 
can  be  more  quickly  and  satisfactorily  carried  out  with  the  patient  in  the  exag- 
gerated lithotomy  posture,  otherwise  known  as  the  Simon  posture. 

Steps.  After  satisfactory  exposure  of  the  fistulous  opening,  the  edges  are  pared 
as  shown  in  Fig.  526.  A  small  sharp  knife  or  curved  scissors  may  be  used,  as  found 
most  convenient.  A  very  good  plan  is  to  outline  the  area  to  be  denuded  with  a 
knife,  so  as  to  give  it  an  even  margin,  and  then  excise  the  tissue  with  the  scissors. 
The  denudation  is  made  extensive  on  the  vaginal  surface  and  slopes  inward  toward 
the  bladder  opening.  The  denudation  must  be  carried  into  sound  tissue  so  that 
primary  union  may  take  place. 

When  possible  the  denudation  should  be  made  in  such  a  way  that  the  line  of 
union  can  be  made  to  lie  somewhat  in  the  long  axis  of  the  vagina.  That  is  prefei- 
able  for  the  reason  that  it  causes  less  disturbance  of  the  pelvic  relations.  When 
the  line  of  union  extends  crosswise  of  the  vagina,  the  antero-posterior  tension  tends 
to  drag  the  cervix  downward  and  cause  retroversion.  The  fistula  should  be  closed, 
however,  in  the  way  that  will  permit  accurate  approximation  without  injurious 
tension.  In  case  the  opening  is  round,  a  V-shaped  denudation  may  be  made  at 
each  end  to  permit  accurate  approximation  in  a  straight  line  without  too  much 
tension.  If  necessary  the  edges  may  be  brought  together  in  the  shape  of  an  X 
or  a  Y. 

The  oozing  of  blood  may  be  largely  checked  by  the  appUcation  of  a  small  cotton 
or  gauze  sponge  wrung  out  of  very  hot  water,  or  by  irrigating  with  hot  water. 
The  denudation  should  not  extend  into  the  vesicle  mucosa  as  it  may  start  bleeding, 
that  may  continue  to  prove  troublesome  even  after  the  suture  are  passed  and  tied. 
In  some  cases,  after  such  operation,  blood  clots  have  formed  in  the  bladder  to  such 
an  extent  that  the  wound  had  to  be  reopened. 

The  sutures  are  passed  as  shown  in  Fig.  525. 
They  enter  the  vaginal  mucosa  -4  to  -t  an  inch 
from  the  margin  of  the  denuded  area,  pass 
into  the  bladder  sub-mucosa,  emerge  near  the 
bottom  of  the  denuded  area  and  then  pass 
through  corresponding  tissues  on  the  opposite 
side  of  the  wound.  They  do  not  appear  on 
the  vesical  surface. 

The  sutures  are  passed  at  intervals  of  about 
Fig.  52.5.    The  Course  of  the  Needle        ouc-fourth  of  an  inch.     They  may  consist  of 

in  suturing  a  vesico-vaginal   fistula,     v.  .  i-    r>rv     i  ,        ,  k  a  i\ 

Vaginal     surface.       b.   Bladder     surface.  SllkWOrm-gUt    OT  Ot    20-day    CatgUt.       After    the 

The  needle  passes  to,  but  does  not  in-        suturcs  are  passed  the  bladder  should  be  washed 

elude,   the    bladder    mucosa.       (Skene —  ,ir-  .1  ,•     ^      j  ^  ,1111        1 

Diseaseii  of  Women.-)  out  bciorc  they  are  tied,  to  wash  out  all  blood 


TREATMENT  OF  VESICO-VAOINAL 


515 


from  it.     The  sutures  are  then  tied  and  cut,  and,  if  desired,  the  bladder  may  be 
filled  with  boric  acid  solution  (3%)  to  see  if  there  is  any  leakage. 

It  is  preferable  in  most  cases  to  first  close  the  deeper  portions  of  the  wound  with 
buried  sutures,  as  shown  in  Fig.  526. 

A  very  useful  expedient,  especially  when  there  is  much  loss  of  tissue  and  decided 
tension  in  bringing  the  sides  together,  is  to  incise  the  vaginal  surface  around  the 
fistula,  as  shown  in  Fig.  527,  and  then  turn  in  the  edges  without  cutting  any  off. 
The  raw  surfaces  of  the  turned-in  flaps 
are  sutured  together  by  buried  sutures 
(Fig.  528)  and  then  the  vaginal  mucosa  is 
closed  over  by  continuous  or  interrupted 
suture  as  desired  (Fig.  528). 

After  the  fistula  is  sutured,  a  light 
packing  of  antiseptic  gauze  is  placed  in 
the  vagina,  the  soft-rubber  retention 
catheter  is  introduced,  if  it  is  to  be  used,  a 
dressing  is  applied  over  the  vulva  and 
the  patient  is  put  to  bed. 

The  after=treatment  is  the  same  as 
after  repair  of  laceration  of  the  pelvic 
floor,  with  the  addition  of  frequent 
catheterization  or  constant  bladder  drain- 
age by  means  of  the  retention  catheter. 
When  the  retention  catheter  is  used,  it  is 
left  in  from  three  to  eight  days,  depending 
on  the  case,  and  after  that  the  patient 
urinates  or  is  catheterized  every  six  hours 
until  the  wound  is  firmly  healed. 

If  preferred,  the  bladder  may  be  emp- 
tied by  catheter  every  three  to  six  hours 
for  the  first  two  or  three  days,  the  reten- 
tion catheter  being  thus  entirely  dis- 
pensed with.  With  a  reliable  trained 
nurse  in  attendance,  the  frequent  cathet- 
erization is  fairly  safe,  but  without  such 
an  attendant,  the  retention  catheter  is 
safer.  When  it  is  used  it  should  be  removed  and  sterilized  each  day  and  the 
bladder  washed  out  with  boric  acid  solution  (3%).  It  is  well  to  leave  the  catheter 
out  for  an  hour  or  two  for  a  change.  As  long  as  catheterization  is  necessary,  the 
bladder  should  be  washed  out  with  boric  acid  solution  (3%)  either  once  of  twice 
daily  or  after  each  catheterization.  When  the  retention  catheter  is  in  place,  the 
patient  may  lie  in  the  prone  or  semi-prone  posture  to  favor  drainage.  In  severe 
cases  it  may  be  advisable  to  keep  her  in  this  posture  most  of  the  time,  until  the 
opening  is  healed. 

In  mild  cases,  no  special  care  is  necessary  except  to  administer  the  urinary  anti- 


Fig.  526.  The  Regular  Operation  for  Vesico- 
vaginal Fistula.  Showing  the  area  of  Denuda- 
tion and  also  the  Deep  Sutures.  (Montgomery— 
Practical  Gynecology.) 


516 


LACERATIONS  AND    FISTULA 


septic  and  to  see  that  the  bladder  is  emptied  every  four  to  six  hours,  either  spon- 
taneously or  by  catheter. 

The  sutures  are  removed  in  twelve  to  fifteen  days. 

Special  measures.  There  are  various  special  measures  required  by  special  con- 
ditions. 

In  cases  in  which  there  are  bands  of  scar-tissue  in  the  vagina,  which  hold  the  edges 
of  the  fistula  apart,  it  is  sometimes  advantageous  to  divide  these  bands  in  the  pre- 
liminary treatment,  and  separate  the  divided  bands  widely  by  a  glass  plug. 


Fig.  527.  The  Flap  Operation  for  Vesiro-vagina! 
Fistula.  Making  the  Incision  for  turning  in  the 
flap.  The  "flap  operation"  is  especially  useful 
where  there  has  been  loss  of  tissue.  (Montgomery 
— Practical  Gynecology.) 


Fig.  528.  The  Flap  Operation  for  Vesico-vaginal 
Fistula.  The  flap  has  been  turned  in  and  the 
Deep  Sutures  passed  and  tied.  The  Superficial  Su- 
tures also  are  in  place.  If  preferred,  continuous 
sutures  may  be  used  throughout.  (Montgomery — 
Practical  Gynecology.) 


In  severe  cases,  there  is  danger  of  occlusion  of  a  ureter,  by  a  ligature  or  by  an 
opposing  surface.  This  accident  is  indicated  by  increasing  pain  in  the  region  of 
one  kidney  and  along  the  ureter,  accompanied  by  a  decided  diminution  in  the 
amount  of  urine  secreted.  It  recjuiros  the  removal  of  one  or  more  sutures.  To 
prevent  occlusion  of  the  ureter  a  cystoscopic  examination- should  be  made  ^vhenever 
the  position  of  the  fistula  is  such  as  to  make  it  probable  that  one  of  the  ureters  enters 
it  or  lies  close  to  it.     By  cystoscopic  examination,  the  ureteral  opening  may  be 


TREATMENT  OF  VESICO-VAGINAL  FISTULA  517 

located  and,  if  it  is  dangerously  near  the  fistula,  a  ureteral  catheter  may  be  intro- 
duced, that  the  ureter  may  be  better  located  during  the  operation  and 
avoided. 

In  the  severer  cases,  where  there  is  much  loss  of  tissue  and  scar  contraction,  it 
may  be  necessary  to  employ  one  or  more  of  the  special  measures  mentioned  under 
recto-vaginal  fistula,  such  as  remote  incisions  of  the  vaginal  mucous  membrane 
or  transplantation  of  flajw  of  the  mucosa.  There  are  other  special  measures  that 
are  useful  in  certain  cases,  such  as  the  following: 

a.  Separation  of  the  bladder  wall  from  the  uterus  and  upper  part  of  the  vagina, 
sufficiently  to  permit  its  being  pulled  down  and  sutured  to  the  lower  edge  of  the 
opening  without  much  tension. 

b.  Drainage  of  the  bladder  by  suprapubic  cystotomy.  Satisfactory  drainage 
can  usually  be  secured  with  a  retention  catheter  in  the  urethra.  In  certain  cases 
however  the  neck  of  the  Ijladder,  and  consequently  part  of  the  urethra,  is  in  the 
damaged  area  and  is  necessarily  involved  in  the  operative  work.  In  such  a  case, 
if  a  catheter  be  left  in  the  urethra,  the  tissues  in  the  neck  of  the  l^ladder  immediately 
about  the  catheter,  fail  to  heal,  resulting  in  incontinence  of  urine.  In  such  a  case, 
the  bladder  may  be  drained  and  kept  at  rest  by  suprapubic  cystotomy  and  constant 
drainage.  Another  method  of  dealing  with  these  cases  is  to  make  the  operation 
in  two  stages — repairing  first  the  urethral  injury  and  draining  the  bladder  by  the 
fistula,  and  latei  closing  the  fistula  and  using  the  urethra  for  drainage. 

The  difficulties  of .  operation  vary  much  in  different  cases.  A  small  vesico- 
vaginal fistula  is  easily  repaired  and  usually  heals  without  trouble.  In  the  case  of 
a  large  fistula  in  which  the  edges  can  be  easily  brought  together  with  tenacula, 
or  can  be  brought  so  near  together  that  lateral  incisions  will  permit  perfect  approxi- 
mation, there  is  but  little  difficulty  for  an  experienced  operator.  It  requires  con- 
siderable experience  in  plastic  surgery  to  be  able  to  judge  in  some  cases  before  an 
operation  whether  or  not  such  approximation  can  be  secured.  If  it  cannot  be 
secured  some  other  measure  must  be  adopted  and  planned  for  in  detail,  before 
the  day  of  operation. 

In  some  cases,  with  the  best  of  care,  two  or  three  operations  may  be  required  to 
effect  a  cure,  the  fistulous  opening  being  decidedly  reduced  in  size  with  each  oper- 
ation. But  the  operator  must  have  a  clear  understanding  of  what  is  to  be  accom- 
plished in  that  particular  case  by  each  operation.  As  Kelly  remarks  in  his  ad- 
mirable work:  "It  is  worse  than  useless  to  denude  the  edges  of  a  large  fistula, 
without  having  any  definite  idea  of  what  can  be  accomplished  until  the  stitches 
are  put  in  and  pulled  upon.  It  would  be  far  better  to  let  the  patient  entirely  alone, 
and  confess  honestly  an  inability  to  relieve  her,  than  to  go  on  cutting  away  valuable 
tissue  and  increasing  the  size  of  the  fistula  every  time,  with  a  vague  idea  that  by 
some  chance  the  operation  may  succeed." 

There  are  cases  of  vesico-vaginal  fistula  presenting  a  contracted  bladder  and  with 
scar-tissue  extending  in  various  directions  binding  the  edges  of  the  fistula  to  ad- 
jacent bones,  that  tax  to  the  utmost  the  skill  and  ingenuity  of  the  operator,  who 
must  devise  some  way  of  bringing  the  urinary  stream  within  control  of  the  sphincter 
vesicae  and  of  providing  a  bladder-cavity  large  enough  to  hold  a  few  hours  urine. 


518  LACERATIONS  AND  FISTULA 

Other  Urinary  Fistulae. 

Occasionally  there  occur  other  varieties  of  urinary  fistulse,  opening  into  the 
genital  tract.  There  may  be  an  opening  into  the  vagina  from  the  ureter  of  one  or 
both  sides,  or  there  may  be  an  opening  into  the  cervix  uteri  from  the  bladder  or 
from  the  ureter. 

The  usual  causes  of  these  fistulse  are  severe  laceration  of  the  cervix  in  labor  or 
some  operation  at  the  vaginal  vault.  The  fistula  appears  as  a  small  opening  in  the 
scar-tissue,  from  which  urine  escapes.  If  due  to  injury  during  operation,  the  injury 
may  have  been  caused  by  a  tear  of  the  bladder  wall  while  separating  it  from  the 
uterus,  by  a  bite  of  a  ureter  or  the  bladder  by  the  tip  of  a  pressure-forceps,  by  a 
puncture  of  a  ureter  or  the  bladder  by  a  ligature-carrier,  or  by  inclusion  of  a  ureter 
in  a  ligature. 

When  due  to  an  injury  during  labor,  the  vesico-uterine  fistula  is  caused  by  a 
severe  laceration  of  the  cervix  extending  up  into  the  vaginal  vault  and  through 
the  bladder  wall.  The  lower  portion  of  the  cervical  wound  heals,  but  the  upper 
part  communicating  with  the  bladder  fails  to  heal,  and  there  is  left  an  opening 
from  the  bladder  into  the  cervical  canal. 

In  the  ureteral  fistulse,  if  one  ureter  only  is  involved,  there  will  be  leaking  of  urine 
into  the  vagina  and  at  the  same  time  urine  from  the  other  ureter  will  be  received 
and  contained  in  the  bladder  and  passed  normally.  If  both  ureters  are  involved, 
all  the  urine  will  pass  into  the  vagina  and  none  into  the  bladder.  In  either  case, 
if  methylene-blue  solution  be  injected  into  the  bladder,  none  of  it  will  pass  through 
into  the  vagina.  When  the  fistula  is  connected  wth  a  ureter,  the  urine  comes  in 
little  gushes  at  intervals  of  several  seconds. 

The  vesico-uterine  and  uretero-uterine  fistulse  are  indicated  by  the  escape  of 
urine  from  the  cervical  canal.  Colored  water  injected  into  the  bladder  comes  out 
of  the  cervical  canal  if  the  fistula  is  connected  with  the  bladder,  but  not  if  it  is 
connected  with  the  ureter. 

These  fistulse  at  the  vault  of  the  vagina  often  close  spontaneously  after  a  few 
weeks,  the  vagina  in  the  meantime  being  kept  clean  by  frequent  antiseptic  douches. 
If  a  fistula  persists  after  several  weeks  with  no  apparent  prospect  of  closing,  it  will 
be  necessary  to  close  it  by  operation.  Occasionally  the  fistula  may  be  closed  by 
a  small  operation,  for  example,  in  the  vesico-uterine  fistula  if  the  fistula  is  near 
the  free  margin  of  the  cervix,  the  cervix  may  be  split  up  to  the  fistula,  the  infil- 
trated margins  of  the  fistula  excised,  and  the  whole  area  closed,  much  the  same  as 
an  ordinary  cervical  laceration,  with  the  addition  of  a  few  extra  sutures  for  the 
bladder  wall.  If  the  fistulous  tract  is  situated  high  in  the  cervix  the  operation  will 
involve  separation  of  the  bladder  from  the  uterus  and  separate  closure  of  the  two 
wounds.  This  may  be  Carried  out  through  vaginal  dissection  or  by  abdominal 
section,  as  found  most  convenient.  The  majority  of  fistulse  at  the  vaginal  vault 
require  rather  extensive  operative  procedures,  vaginal  or  abdominal  (depending 
upon  the  character  and  location  of  the  fistula),  and  in  most  cases  the  procedures 
can  be  carried  out  satisfactorily  only  ])y  one  familiar  with  pelvic  and  abdominal 
operative  work.  Occasionally  nephrectomy  is  advisable,  to  stop  the  continuous 
leakage  of  urine  from  a  ureteral  fistula  that  cannot  be  repaired. 


OTHER  URINARY  FISTUL^E  519 

DESTRUCTION  OF  URETHRA. 

The  condition  to  which  I  refer  here  is  destruction  of  the  urethra  by  nictation 
beginning  in  the  vestibule  and  extending  upward  to  the  bladder.  The  urethra  is 
destroyed  as  far  as  fiuiction  is  concerned  and  there  remains  simply  an  opening  from 
the  bladder  to  the  external  genitals,  through  which  the  urine  constantly  dribbles. 

The  destructive  ulceration  is  usually  syphilitic.  The  treatment  is  to  restore  the 
urethra  by  a  plastic  operation.  The  cases  often  prove  very  rebeUious  to  operative 
treatment,  it  being  particularly  difficult  to  secure  restoration  of  the  sphincter 
function.  The  cause,  course  and  effective  treatment  of  this  troublesome  affection 
are  given  in  detail  in  a  paper*  which  I  read  before  the  St.  Louis  Obstetrical 
and  Gynecological  Society, 


*  A  Vesico-vaginal  Opening  as  a  means    of  Bladder  Drainage  in   Extensive  Plastic  Work  on 
the  Urethra,  by  H.  S,  Crossen,  M.  D.     American  Journal  of   Obstetrics,  1899. 


520 


CHAPTER  yi. 

DISEASES  OF  THE  UTERUS. 

POINTS  IN  ANATOMY. 

The  uterus  is  situated  about  the  center  of  the  pelvic  cavity,  between  the  bladder 
and  the  rectum  (Figs.  1,  3,  593).  It  projects  upward  into  the  lower  part  of  the 
peritoneal  cavity,  and  its  convex  surface,  except  the  lower  portion,  is  enveloped 
by  peritoneum.  The  upper  end  of  the  uterus  is  directed  forward.  The  lower  end 
is  directed  backward  and  downward  and  projects  into  the  upper  end  of  the  vagina. 
The  uterus  is  freely  movable,  especially  the  upper  portion,  and  may  be  pushed 
backward  by  a  full  bladder  or  forward  by  a  full  rectum. 

The  uterus  is  shaped  somewhat  like  an  inverted  pear  (Figs.  529,  530,  531),     Its 


Reflection  of 
peritoneum. 


Fig.  529.  Anterior  View  of  the  Uterus. 
(Dickinson — American  Textbook  of  Obste- 
trics.) 


Fig.  530.  Antero-posterior  Section  of  Uterus 
showing  walls  and  cavity.  (Dickinson— Ameri- 
can Textbook  of  Obstetrics.) 


lower  constricted  portion  is  called  the  cervix  uteri  (neck  of  the  uterus)  and  to 
this  the  vagina  is  attached.  The  remainrler  of  the  organ  is  called  the  corpus 
uteri  (body  of  the  uterus).  It  is  from  the  upper  portion  of  the  uterus,  the  widest 
portion,  that  the  Fallopian  tubes  arise.  That  portion  of  the  uterus  lying  above 
the  Fallopian  tubes  is  known  as  the  fundus  uteri  (Fig.  531). 

The  uterus  has  a  small  central  cavity  (Figs.  531,532)  which  is  lined  with  mucous 
membrane  and  which  communicates  through  the  vagina  with  the  outside  world 
and  througn  the  Fallopian  tubes  with  tlie  peritoneal  cavity  (Fig.  628).  This 
is  the  only  continuous  opening  from  the  outside  of  the  body  into  the  peritoneal 


POINTS  IN   ANATOMY 


521 


sac,  and  it    is  because  of  this  direct  opening   into   the   peritonael   cavity   that 
peritonitis  is  so  much  more  frequent  in  women  than  in  men. 
The  size  of  the  uterus  is  of  course  different  in  the  different  periods  of  life  (Figs. 

-        .,     ,.      k  -r— J      -  ,  lininvene  ducts 

loiigUudmal  Miict  of  epoophpron  \  o/  tpocpiwron  -.. 

^-^—k- J    ampullQ qjiuba u/crina 

'mesosalpinx  ,-  "'  ' 


fundus  of  uterus 


uterine  orifice 
of  tubc\   ,-- 


serous  ,j- 
cont 

body  0}  utenisi^ 


musculai 
coat  f 

mucous  coat 


supravaginal       ' 
portion  of  cenn 


vaginal  poitton^   7- 
of  cervix 


appendix, 
vesiculosa 
cavity  of  uterus  niesov'arian      folliculi  vesiculasi 

border  of  ovary 


canal  of  cervix 
plica  palmata 


\  infundibuluin 
fimbria  avarica 


vagina 


-  external  os  uteri 
\aginal  rugae 

-  posterior  column  of  rugae 

body  of  uteius 


supravaginal  poit  on/i 
of  cervix  \\ 


fundus  of  utenis 


cavity  of  uterus 


canal  of  cervix 


anterior  iij}^ ,  -^^w  ,  ^^ 

posterior  fornix 
of  vagina 


]iiml  iiortion  of  cervix. 


Kg.  531.  The  Uterus  and  the  Right  Fallopian  Tube  and  the  Right  Ovary,  laid  open.  View  from  behind.  In 
the  right  lower  comer,  an  Antero-posterior  Section  of  the  Uterus  is  shown.  (Sobotta  and  McMurrich— fl^umaw 
Anatomy.) 

533,  534,  535).  At  birth  it  is  a  trifle  over  one  inch  long  and  the  cervix  comprises 
two-thirds  of  the  organ  (Fig.  536).  It  is  important  to  keep  in  mind  the  pecul- 
iarities of  the  infantile  uterus,  for  occasionalUy  an  adult  presents  a  uterus  some- 


522 


DISEASES  OF  THE  UTERUS 


what  infantile  and  accompanied  with  troublesome  symptoms  due  to  lack  of  de- 
velopment. A  rather  common  condition  and  a  very  troublesome  one  (see  dysmen- 
orrhoea)  is  a  sharp  anteflexion  of  the  cervix — the  corpus  uteri  being  in  practically 
normal  position,  but  the  cervix  being  flexed  sharply  forward  and  directed  along 
the  vaginal  canal  toward  the  opening.     In  the  fetus,  the  uterus  lies  very  high  and 


Fig.  532.  Reconstruction  of  the 
uterus,  showing  the  shape  of  the 
ca\'ity.     (yii\lia,ms— Obstetrics.) 


Fig.  533.     Uterus    and    Appendages   of    a 
Young  Child.      (WilUams — Obstetrics.) 


Fig   J    1       1         I     and  Tube    and  Ovary  of  a  Fourteen- 
year-old  Gill       i\\  i\ha,ms— Obstetrics.) 


Fig.  ')'■',.'}.     Uterus  and  Tube  and   Ovary  of   a  Twenty-year- 
old  Mutipara.      (Williams— O^^.s^firJcs.) 


the  cervix  is  very  large.  At  first  the  axis  of  the  cervix  lies  almost  In  the  axis  of 
the  vagina,  as  shown  in  Fig.  536.  Normally,  as  development  progi"es.ses,  the 
corpus  uteri  gradually  comes  forward  and  the  cervix  becomes  directed  somewhat 
backward,  across  the  vaginal  axis,  as  shown  in  Fig.  537.  In  the  ca.ses  of  imperfect 
development  above  refei-red  to,  the  corpus  uteri  comes  forward  normally  Init  the 


POINTS  IN  ANATOMY 


523 


Fig.    536.      Vertical   mesial    section    of   the  pelvis  of    a    large  fetus  at 
time  of  birth.     (Webster— Diseases  of  Women.) 


Fig.  537.      Antero-posterior  section  of  the  pehis  of  an  infanc. 
(Tait— Gynecology  and  Abdominal  Surgery.) 


524 


DISEASES  OF  THE  UTERUS 


cervix  fails  to  assume  its  backward  direction — remaining  in  practically  the  fetal 
position  (directed  along  the  axis  of  the  vagina)  and  causing  a  sharp  "  anteflexion 
of  the  cervix"  (Fig.  330). 

The  adult  virgin  uterus  is  three  inches  long  (cavity  2^  inches)  and  the  cervix 
forms  one-third  of  the  organ.  The  transverse  measurement  at  the  widest  part 
is  one  and  a  half  to  two  inches,  and  the  average  thickness  is  one  inch.  It  weighs 
an  ounce  to  an  ounce  and  a  half.  After  childbirth  the  uterus  is  always  a  little 
larger  than  the  virgin  uterus  (Fig.  538) .  This  is  the  kind  most  frequently  requir- 
ing examination.  The  cavity  measures  two  and  one-half  to  three  inches.  After 
the  menopause  there  is  marked  atrophy  of  all  the  genital  organs,  including  the 


Fig.  538. 
Obstetric*.) 


Fallopian 
tube 

Round 
Li^ajnent 


Body  ofUtei-LLs 
Isthmus 


Extra  Vaqinal 
portion  of  Cervix. 

Zxterncd  os 


Paste rLor  Wall  of 

A  Comparison  of  the  Nulli parous  Uterus  with  the  Multiparous  Uterus.     (Edgar— Practice  of 


uterus.  The  extent  of  the  atrophy  of  the  uterus  is  variable.  In  the  very  aged 
it  may  be  reduced  to  a  nodule  the  size  of  the  end  of  the  thumb,  and  the  cervix 
then  no  longer  projects  into  the  vaginal  cavity,  but  is  felt  simply  as  an  indurated 
area,  with  a  small  central  opening,  situated  in  the  upper  part  of  the  anterior 
vaginal  wall. 

Structure  of  the  Uterus. 

The  uterus  is  a  hollow  muscle.  The  central  cavity  is  lined  with  mucous  mem- 
brane wiiile  the  external  surface  of  the  muscle  is  covered  with  peritoneum.  The 
wall  of  the  uterus  is  therefore  composed  of  three  layers — peritoneal  muscular, 
and  mucous  (Figs.  530,  531). 

1.  Peritoneal  layer.  This  forms  a  delicate  serous  covering  to  the  uterus.  It 
does  not  differ  materially  from  peritoneum  elsewhere.  There  are  certain  portions 
of  the  uterus  which  are  not  covererl  liy  peritoneum,  namely,  the  lateral  portions 
of  the  body  and  the  front  and  sides  of  the  cervix  (Fig.  539). 


POINTS  IN   ANATOMY 


525 


2.  Muscular  layer.  This  is  the  real  wall  of  the  uterus.  It  is  h  to  f  of  an 
inch  thick  and  is  composed  of  involuntary  muscular  tissue.  Under  the  micro- 
scope, the  principal  elements  are  seen  to  be  the  long  muscle  cells.  They  are  fusi- 
form in  shaj^e  and  are  arranged  in  parallel  rows.  These  rows  of  muscle  cells  are 
arranged  in  bundles  that  extend  in  various  directions. 


Fig.  539.     Showing  the  Relations  of  the  Uterus  to  the  Vagina  and  Bladder 
and  Peritoneum.      (Dickinson —American  Text-book  of  Obstetrics.) 


The  muscular  wall  of  the  uterus  is  divided  somewhat  into  strata.  In  the  unim- 
pregnated  uterus  the  different  strata  are  not  clearly  defined,  but,  speaking  in  a 
general  way,  it  may  be  said  that  the  muscular  bundles  are  arranged  in  three  strata 
— a  thin  outer  longitudinal  stratum,  a  thick  middle  stratum  of  interlocking  bundles 
extending  in  various  directions,  and  a  thin  inner  longitudinal  stratum. 


muoosa. 


muscLa 


Fig.  540.     Endometrium  of  an  infant,  just  born.      (Williams— 06s<e<;-tcs.) 


The  connective  tissue  of  the  muscular  layer  comprises  most  of  the  connective 
tissue  of  the  uterus.  It  is  not  distributed  in  the  form  of  distinct  strata,  but 
appears  as  irregular  masses  surrounding  and  supporting  the  important  elements. 
There  is  a  very  intimate  connection  between  the  mucous  membrane  Uning  the 
uterus  and  the  connective  tissue  of  the  muscular  layer. 


526 


DISEASES  OF  THE  UTEllUS 


The  blood  vessels  of  the  muscular  layer  include  most  of  the  vessels  of  the  uterine 
wail.  The  arteries  are  distinguished  in  a  microscopic  section,  by  their  thick  walls 
and  folded  intima.  The  outer  vessels  run  in  a  longitudinal  direction,  while  the 
inner  vessels  run  perpendicular  to  the  mucous  surface.  There  is  a  dense  capillary 
network  close  to  the  mucous  membrane. 

The  veins  are  very  large  and  have  thin  walls. 

The  lymphatics  of  all  the  coats  of  the  uterus  (peritoneal,  muscular  and  mucous) 
empty  into  large  lymphatic  vessels  in  the  external  muscular  stratum.  These  in 
turn  empty  into  efferent  trunks  at  the  sides  of  the  uterus. 


PARKER. 


Fig.  541.  Endometrium  of  the  cliild-bear- 
ing  period.  This  specimen  is  from  a  woman 
aged  25  years.  (Dudley— Pro rt ice  of  Gyne- 
cology.) 


Fig.  542.  The  endometrium  after  the  meno- 
pause. Notice  the  diminution  in  thickness 
and  the  scarcity  oi  the  glands.  Both  speci- 
mens are  magnified  to  the  same  extent. 
(Dudley— Prac^'ce  of  Gynecology.) 


The  nerves  of  the  muscular  layer  are  derived  from  the  sympathetic.  The  fila- 
ments ramify  among  the  muscular  bundles  and  terminate  in  the  nuclei  of  the 
muscle  cells. 

3.  Mucous  layer.  The  mucous  membrane  of  the  uterus  lies  directly  on  the 
internal  muscular  stratum,  the  usual  submucous  layer  of  loose  connective  tissue 


POINTS  IN  ANATOMY 


527 


being  absent.  Scattered  muscular  filaments  extend  into  the  mucosa,  so  the  con- 
nection between  the  two  is  firm.  The  mucous  membrane  of  the  body  of  the  uterus 
iS  known  as  the  "  endometrium."  That  lining  the  cervix  is  known  as  the  "  cervical 
mucosa." 

The  endometrium  is  about  yV  of  an  inch  thick  in  the  child-bearing  period,  and  is 
disposetl  over  the  interior  of  the  uterus  as  a  smooth  layer  (Fig.  531,  568).  It  is  soft 
and  velvety  to  the  touch, 
and  when  perfectly  fresh 
has  a  pink  color.  Most  of 
the  specimens  seen  some 
hours  after  removal  of  the 
uterus  have  a  gi'ayish  ap- 
pearance, indicating  a  be- 
ginning post-mortem 
change.  There  is  a  great 
difference  in  the  thickness 
and  general  appearance  of 
the  endometrium  in  the 
different  periods  of  life. 
The  endometrium  in  early 
childhood  is  shown  in  Fig. 
540,  in  adult  life  (child- 
bearing  period)  in  Fig.  541, 
and  after  the  menopause  in 
Fig.  542. 

The  basis  of  the  endo- 
metrium is  a  tissue  com- 
posed almost  exclusively  of 
oval  cells,  somewhat  larger 
than  a  leucocyte  and  hav- 
ing a  round  or  oval  nucleus 
that  stains  lightly  (Fig. 
543).  The  nucleous  is  so 
large  that  it  occupies  most 
of  the  cell  (Fig.  543) .  When 
stained  it  is  reticular,  i.  e., 
it  shows  the  chromatin 
bands  and  does  not  stain  a 

solid  dark  color  as  does  the  nucleus  of  a  lymphocyte.  These  oval  cells  with  the 
large  reticular  nucleus  are  known  as  stroma  cells.  They  are  packed  closely  to- 
gether, with  nothing  separating  them  except  a  few  cell  processes  and  a  small 
amount  of  serous  or  mucoid  inter-cellular  substance.  The  tissue  thus  formed  is 
known  as  cytogenic  tissue.  When  a  specimen  of  it  is  stained,  the  microscopic  field 
seems  to  be  almost  entirely  occupied  by  rounded  or  oval  reticular  nuclei  (Fig.  543). 
The  cell-protoplasm  stains  so  lightly  and  is  so  small  in  amount  that  it  is 
scarcely    noticeable.      The    stroma    cells    may  vary  slightly   in   size  and    shape 


Fig.  543.  A  Microscopic  Section  of  the  Endometrium,  show- 
ing the  Stroma  Cells  and  also  a  cross-section  of  a  Gland. 
The  structures  are  magnified  420  times.    (\\\\\\a.ms— Obstetrics.) 


528  DISEASES  OF  THE  UTERUS 

but  any  general  change  to  a  marked  degree  in  size  or  shape,  means  some  disease 
There  are  normally  no  connective  tissue  fibers  or  muscle  fibers  or  vessels  with  well- 
marked  walls,  in  the  cytogenic  tissue  near  the  free  surface  of  the  mucosa,  though 
all  these  may  appear  in  certain  abnormal  conditions. 

The  free  surface  of  the  endometrium  is  covered  with  a  layer  of  ciliated  columnar 
epithelial  cells  (Fig.  540).  These  have  a  large  reticular  nucleus,  situated  near  the 
center  of  the  cell  but  a  little  closer  to  the  attached  end  than  to  the  free  end  The 
cilia  are  not  seen  in  the  ordinary  preparation  but  come  out  well  in  Fig.  543. 

The  endometrium  contains  many  glands.  These  are  simply  tubular  depressions 
of  the  lining  epithelial  layer  (Fig.  541).  The  epithelial  cells  lining  the  gland;3 
present  the  same  general  characteristics  as  the  cells  on  the  surface  of  the  endo- 
metrium (Fig.  543).  The  glands  are  formed  by  infolding  of  the  epithelial  lining 
of  the  endometrium.  At  puberty  they  increase  in  number  and  at  each  menstrual 
period  they  increase  slightly  in  length. 

Normal  Changes  in  the  Endometrium. 

The  structure  of  the  endometrium  undergoes  normal  changes  due  to  menstru- 
ation, to  pregnancy  and  to  the  menopause. 

Menstruation.  During  menstruation  the  endometrium  becomes  engorged  with 
blood,  and  this,  vriih  some  slight  hypertrophy,  is  essentially  all  the  change  there 
is.  The  marked  gi'owth  of  the  endometrium  followed  by  its  wholesale  disintegra- 
tion, which  was  formerly  supposed  to  take  place,  has  been  found  not  to  occur 
normally.  There  is  simply  marked  engorgement,  which  comes  on  rather  slowly 
and  disappears  slow!5^  As  a  result  of  this  engorgment  the  endometrium  becomes 
much  swollen  and  there  is  extravasation  of  blood  into  the  stroma,  among  the 
stroma  cells  (Fig.  544).  From  there,  part  of  it  finds  its  way  into  the  glands  and 
then  into  the  cavity  of  the  uterus,  while  another  part  of  it  passes  directl}^  through 
the  surface  epithelial-layer  into  the  cavity.  This  extravasation  of  blood  interferes 
somewhat  with  the  nutrition  of  the  epithelium  in  small  areas  and  the  epithelium 
is  thrown  off  over  these  areas  and  appears  in  the  menstrual  discharge  as  single 
cells  or  as  groups  of  cells.  There  may  occasionally  be  a  small  piece  of  stroma  cast 
off,  but  there  is  no  disintegration  of  any  considerable  portion  of  the  endometrium, 
as  formerly  supposed.  In  many  cases  of  ordinary  dysmenorrhoea,  small  pieces 
of  the  endometrium  are  cast  off,  but  these  changes  are  abnormal,  as  are  also  the 
cases  of  marked  "dysmenorrhoea  membranacea."  After  menstruation  the 
extra vasated  blood  which  has  not  passed  into  the  cavity  is  absorbed  from  the  stroma 
together  with  the  remnants  of  those  stroma  cells  that  have  been  so  damaged  that 
they  disintegrate.  In  a  few  days  the  endometrium  has  returned  to  its  normal 
resting  condition.     Menstruation  as  a  function,  is  considered  in  detail  in  chapter 

XIV. 

Pregnancy.  The  changes  in  structure  due  to  pregnancy  are  marked  and  ex- 
ceedingly interesting,  but  a  description  of  them  would  be  out  of  place  here. 

Menopause.  At  the  menopause  the  senile  change  begins  to  be  manifest-.  This 
is  essentially  an  atrophy  of  the  cytogenic  ti.ssue  and  of  the  glands,  with  the  de- 
velopment of  fibrous  tissue  throughout  the  endometrium,  hyaline  changes  in  the 


i 


POINTS  IN  ANATOMY  529 

vessels  and  finally  loss  of  the  surface  epihtoliuni,  so  that  the  endometrium  comes 
to  resemble  scar-tissue.  This  process  extends  over  several  years  and  may  be 
encountered  in  any  stage  of  development.  Many  senile  uteri  present  conditions 
very  different  from  the  normal  ones  here  mentioned,  but  those  different  conditions 
are  due  to  pathological  processes  and  not  to  senility. 


*yS^0^^^^-<^'s^C ;  Xu^i^i%r?«N   ^•-::-j-r  -<5?>/«^feK.,j^ 


Fig.  544.  The  Menstruating  Endometrium.  The  dark  areas  are 
formed  by  extravasated  blood.  The  wavy  canals  are  the  gland- 
cavities.     (A.  Martin — Atlas  of  Gynecology.) 

Peculiarities  6?  the  Cervix  Uteri. 

The  structure  of  the  cervix  differs  from  that  of  the  body  of  the  uterus  in  several 
particulars,  as  follows: 

a.  The  greater  part  of  the  cervix  has  no  peritoneal  covering  (Fig.  539). 

b.  The  muscular  layer  of  the  cervix  has  a  much  larger  proportion  of  connective 
and  hence  is  much  firmer. 

c.  There  are  no  large  venous  sinuses  in  the  cervix  and  the  blood-vessels  have 
thicker  walls  and  smaller  lumina  than  those  of  the  body  of  the  uterus. 

d.  The  mucous  membrane  lining  the  cervix  (cervical  mucosa)  is  disposed  in 
prominent  folds  (Fig.  531).  These  folds  extend  more  or  less  obliquely  outward 
from  two  ridges,  one  situated  near  the  center  of  the  posterior  lip  and  the  other 
near  the  center  of  the  anterior  lip. 

e.  The  glands  of  the  cervix  approach  the  racemose  variety.  They  consist  of 
branching  ducts  with  dilated  ends  (Fig.  545).  The  glands  are  lined  with  columnar 
epithelial  cells  which  are  even  taller  than  those  on  the  surface.  The  nucleus  of 
each  cell  lies  at  the  base.  These  cells  secrete  mucus  which  does  not  stain  appreci- 
ably in  ordinary  preparations  (haematoxylin  and  eosin),  consequently  that  portion 
nf  the  cell  lying  next  to  the  lumen,  which  part  of  the  cell  is  usually  filled  with 
mucus,  appears  clear  (Fig.  545). 

The  glands  of  the  cervix  secrete  a  clear  viscid  tenacious  mucus  that  fills  the 
cervical  canal  and  serves  to  close  it  and  prevent  invasion  of  the  uterine  cavity. 
The  ducts  of  these  glands  sometimes  become  obstructed  causing  retention  cysts 
(Fig.  337).    These  are  sometimes  called  ''ovulae  Nabothi."     There  may  be  many 


530 


DISEASES  OF  THE  UTERUS 


of  them,  in  which  case  the  cervix  is  said  to  be  in  a  state  of  "cystic  degeneration" 
(Figs.  559,  560). 

f.  The  layer  of  cytogenic  tissue  with  characteristic  stroma  cells,  is  compara- 
tively thin  in  the  cervix. 

g.  The  cervical  mucosa  does  not  take  part  in  the  changes  of  menstruation  or 


Fig.  545.  Longitudinal  section  of  a  Gland  of  the 
Cervix.  Tliis  is  evidently  taken  from  near  the  ex- 
ternal OS,  as  the  squamous  epithelium  extends  up 
to  it.  A  cross-section  of  part  of  a  gland  is  shown 
at  the  lower  margin.  (Cullen— Cancer  of  the 
Uterus.) 


pregnancy,  except  in  rare  cases.  It  does,  however,  undergo  the  atrophy  of  seniKt}', 
but  here  the  change  is  not  so  marked  as  in  the  endometrium  for  the  cytogenic 
tissue  is  not  so  abundant. 


Vessels  and  Nerves  of  the  Uterus. 

The  blood  supply  of  the  uterus  comes  from  the  uterine  and  ovarian  arteries. 
The  uterine  artery  of  each  sitJe  arises  from  the  anterior  trunk  of  the  internal  iliac 


POINTS  IN  ANATOMY. 


531 


(Fig.  546)  and  passes  inward  and  downward  ))etween  the  layers  of  the  broad 
liu;auicnt  to  just  above  the  Uiteral  vaginal  fornix.  It  then  turns  upward  und 
runs  in  a  very  tortuous  course  along  the  side  of  the  uterus.  Near  the  top  <jf  the 
uterus  it  joins  the  descending  branch  of  the  ovarian  artery  (Fig.  547). 

As  it  runs  along  the  side  of  the  uterus,  the  uterine  artery  gives  off  many  branches 
which  run  horizontally  about   the   organ   and  supply    various   segments.     These 

Slip  ves. 

i    Hypogastric 


lube 


Fig.  546.     The  Blood  Supply  of  the  Uterus.     Showing  the  Uterine  Artery  as  it  leaves  the  anterior  trunk  of 
the  internal  iliac.     (KeUy— Operative  Gynecology.) 


anastamose  with  corresponding  branches  of  the  opposite  artery.  These  branches 
are  very  tortuous,  the  tortuous  and  spiral  arrangement  being  so  marked  that  they 
have  been  called  the  "curling  arteries"  of  the  uterus.  A  horizontal  branch  of 
considerable  size  at  the  level  of  the  internal  os  is  known  as  the  ''  circular 
artery," 


532 


DISEASES  OF  THE  UTERUS 


The  ovarian  artery  of  each  side  supphes  the  tube,  and  ovary  and  upper  part  of  the 
uterus.  They  correspond  to  the  spermatic  arteries  in  the  male  and  arise  directly 
from  the  aorta.  The  artery  of  each  side  passes  downward  and  enters  the  broad 
ligament.  After  giving  off  the  branches  that  supply  the  ovary,  the  artery  passes 
on  to  the  upper  part  of  the  uterus  where  it  divides  into  two  branches.  The  upper 
branch  supplies  the  funrlus  uteri  and  anastamoses  with  the  corresponding  branch 
of  the  opposite  artery.  The  lower  and  larger  branch  descends  along  the  side  of 
the  uterus  and  anastamoses  ^^dth  the  uterine  artery.     Some  authorities  describe 


Fig.  547.     The  Blood  Supply  of  the  Utenis.     Showing  the  course  of  the  uterine  artery  along  the  side  of  the 
uterus.     The  ovarian  vessels  also  are  shown.     (Kelly— Operrt/ire  Gynecology.) 


the  uterine  artery  as  supplying  ;dl  of  the  side  of  the  uterus  and  a  part  of  the  tube, 
and  anastamosing  with  the  ovtirian  artery  some  distance  out  along  the  tube.  Pos- 
sibly the  distribution  differs  considerably  in  different  individuals. 

The  veins  of  the  uterus  are  exceedingly  numerous.  The  organ  is  sunouudcd 
by  a  vast  network  of  these  vessels,  which  receive  the  blood  from  the  veins  and 
sinuses  within  its  walls.  There  is  free  communication  of  these  plexuses  .with  the 
vaginal  and  vesicul  ])lexus('s  below  and  with  the  ovurian  (pampiniform)  plexus 
above,  the  blood  lilt iiiialclv  emptying  into  the  intern.-il  iliac  vein. 


POINTS  IN   ANATOMY 


53Z 


An  important  fact,  from  a  surgical  standpoint,  is  that  in"  the  median  line  the 
uterus  is  almost  free  of  blood-vessels — so  much  so  that  it  may  ])c  bisected  (as  is 
frequently  done  in  vaginal  hysterectomy)  with  Init  little  hemorrhage. 

The  lymphatics  of  the  uterus  may  be  divided  into  two  groups,  the  lymphatics 
of  the  cervix  and  the  lymphatics  of  the  body  of  the  uterus,  as  shown  in  Fig.  54S. 
The  lymphatics  of  the  cervix  uteri  join  with  those  of  the  upper  part  of  the  vagina 
and  empty  into  the  sacral  and  hypogastric  and  superior  iliac  glands.  The  lym- 
phatics from  the  corpus  uteri  join  with  those  of  the  tube  and  ovary  and  empty 
into  the  lumbar  glands.  A  few  lymphatics  from  the  uterine  cornua  pass  along  the 
round  ligaments  and  empty  into  the  inguinal  glands.  The  distribution  the  of 
uterine  lymphatics  to  the  various  glands  is  shown  in  Fig.  549. 


Ovary.  "''/o'J,^/"'  Lymphatica  of  body  and  fundus. 


Lymphatics 

from  the  body 

passing  to 

lumbar 

glands. 

Lymphatics 

of 

Fallopian 

tube. 

Lymphatics 

of 

Fallopian 

tube. 


Lymphatic 
ring. 


Lymphatics 
of  cervix. 


Lymphatics 

fromthebody 

passing  to 

lumbar 

glands. 


Fallopian^ 
tube. 


Lymphatics 
of  round 
ligament. 


Lymphatics 
of  the  cervix. 


•  Vagina. 

Fig.  548.     Tha  Lymphatics  of   the   Uterus.      The  collection  of  the  lymphatic  vessels  of  each  side   into    two 

groups-    one    from    the   cervix    uteri    and   the    othsr    from   the    corpus    uteri,    \e  well    shown.  (Poirier — The 
Lymphatics.) 


The  nerves  of  the  uterus  are  derived  from  the  hypogastric  plexus  of  the  sympa- 
thetic and  from  the  third  and  fourth  sacral  nerves  of  the  central  nervous  system. 


Ligaments  of  the  Uterus. 

The  uterus  is  held  in  its  position  by  the  pelvic  floor  and  by  certain  ligaments 
(Fig.  550).  The  ligaments  are  eight  in  all,  four  on  each  side.  They  are  the  broad 
ligaments,  the  round  ligaments,  the  sacro-uterine  ligaments  and  the  vesico-uterine 
ligaments. 

The  vesico=uterine  ligaments  are  simply  folds  of  peritoneum  extending  from  the 
uterus  to  the  bladder,  as  shown  in  Fig.  550. 

The  sacro=uterine  ligaments  are  similar  folds  of  peritoneum  extending  from  the 


534 


DISEASES  OF  THE  UTERUS 


Fig.  549.     The    Distribution    of   the  Lymphatics  of  the  Uterus  to  tlie  various  Grouus  of  Glands.     (DiJder- 
leiD  and  Krdmg—Operative  Oynakologie.) 


POINTS  IN  ANATOMY 


535 


uterus  around  the  rectum  to  the  sacrum  (Figs.  4  and  550).  They  contain  also 
some  fibrous  tissue  and  a  few  muscuhir  fibers,  hence  they  are  stronger. 

The  round  ligament  of  each  side  is  a  fibro-muscular  cord  which  arises  from  the 
top  of  the  uterus  just  in  front  of  the  Fallopian  tube  and  extends  outward  and 
forward  in  the  upper  part  of  the  broad  ligament  to  the  internal  inguinal  ring(Figs.  5 
and  550) .  It  then  passes  through  the  inguinal  canal  and  at  the  external  ring  divides 
into  fibrous  filaments  wliich  are  lost  in  the  tissues  covering  the  pubic  joint  (Fig.  5). 
The  round  ligaments  are  four  or  five  inches  in  length  and  tend  to  prevent  marked 
Viackward  displacement  of  the  uterus.  Ordinarily  they  are  lax  but  when  the  uterus 
is  displaced  backwards  by  a  full  bladder  or  other  condition,  they  are  made  tense 
and  help  to  bring  the  uterus  back  to  its  accustomed  position.  It  is  the  round 
ligaments  that  are  shortened  in  certain  operations  for  the  cure  of  backward  cUs- 
placement  of  the  uterus. 

The  broad  ligament  of 
each  side  extends  from  the 
lateral  portion  of  the  uterus 
to  the  pelvic  wall  (Fig.  550). 
The  attachment  to  the  ute- 
rus extends  all  along  the 
side  of  the  organ  from  the 
cervix  to  the  fundus,  and 
there  is  a  correspondingly 
wide  attachment  to  the 
pelvic  wall.  This  gives  a 
broad  band  of  tissue  (hence 
the  name  "broad"  liga- 
ment) extending  from  the 
lateral  margins  of  the  ute- 
lus  to  the  pelvic  wall  and 
holding  the  uterus  in  its 
appointed   position   in   the 

center  of  the  pelvic  cavity  (Figs.  4,  550).  Each  broad  ligament  is  composed  of 
two  layers  of  peritoneum  (Fig.  539),  and  between  them  are  a  number  of  important 
structures.  This  disposition  of  the  peritoneum  and  consequent  formation  of  the 
broad  ligaments,  is  represented  very  well  by  a  thin  cloth  laid  over  the  pelvis 
and  then  tucked  down  snugly  around  the  pelvic  organs.  The  peritoneum  cover- 
ing the  anterior  surface  of  the  uterus,  when  continued  laterally  forms  the  anterior 
layer  of  the  broad  ligament,  and  that  covering  the  posterior  surface  of  the  uterus, 
continued  laterally,  forms  the  posterior  layer  of  the  broad  ligament.  Between 
these  two  layers  of  peritoneum  is  a  considerable  amount  of  connective  tissue  and 
also  the  following  important  structures: 

a.  Fallopian  tube  (Figs.  3,  4,  5). 

b.  Ovary  (Fig.  4).  This  is  not  really  situated  in  the  broad  ligament  but  rather 
on  the  posterior  surface  of  the  ligament.  There  is,  however,  a  break  in  the  peri- 
toneum at  this  point  through  which  the  hilum  of  the  ovary  is  in  direct  continua- 
tion with  the  connective  tissue  and  vessels  of  the  broad  ligament  (Fig.  672). 


Fig.  550.     The    Ligaments  of    the  Uterus.     (Hodge — Diseases 
Peculiar  to  iromen.) 


536  DISEASES  OF  THE  UTERUS 

c.  Parovarium  (Figs.  531,  681,  682). 

d.  Ovarian  vessels  (Fig.  547). 

e.  Round  ligament  (Figs.  5,  550). 

f.  Uterine  vessels  (Figs.  546,  547). 

g.  Ureter.  The  ureter,  in  its  course  to  the  bladder,  lies  in  the  lower  part  of  the 
broad  Hgament,  near  the  cervix  and  just  under  the  uterine  artery  (Figs.  546,  547, 
549). 

PATHOLOGICAL  CHANGES. 

By  the  term  "pathological  changes"  as  here  used,  I  do  not  refer  to  diseases, 
but  only  to  indiviudal  structural  changes,  as  encountered  in  various  combi- 
nations in  the  inflammatory  and  nutritive  diseases  of  the  uterus. 

An  entirely  satisfactory  classification  of  the  inflammatory  and  nutritive  dis- 
eases of  the  uterus  is  not  possible  along  the  simple  lines  which  suffice  in  some 
other  localities. 

A  SYMPTOMATIC  classification  is  found  wanting  because  cases  giving  the  same 
symptoms  may  present  very  different  etiological  factors  and  pathological  condi- 
tions— in  fact,  the  same  case  may  show  several  distinct  pathological  changes  in 
combination.  On  the  other  hand,  a  classification  strictly  according  to  etiology 
or  pathology  alone,  is  not  satisfactory,  for  the  same  etiological  factors  may  give 
rise  to  various  pathological  changes,  and,  again,  pathological  changes  essentially 
the  same,  may  give  rise  to  various  clinical  pictures.  So  true  is  this,  that  in  many 
cases  it  is  impossible,  from  the  symptoms  and  usual  examination-signs,  to  deter- 
mine certainly  the  etiology  of  the  trouble  or  the  exact  pathological  changes  pres- 
ent. 

I  think  the  best  way  to  present  this  subject  is  to  give  first  the  essential  patho- 
logical changes  that  take  place  in  the  uterus  as  the  result  of  inflammatory  and 
nutritive  disturbances,  and  then  to  take  up  the  separate  diseases,  classified  largely 
according  to  symptoms  but  bearing  in  their  titles  such  etiologic  and  pathologic 
distinctions  as  are  usually  easily  determined. 

The  nutritive  changes  found  in  the  uterus  are  due  largely  to  modifications  in 
the  quantity  or  quality  of  the  blood  supplied  to  the  tissues,  through  the  innerva- 
tion and  the  lymph  flow,  probably  exercises  some  influence.  The  quantity  and 
quality  of  blood  supplied  to  the  uterus  may  be  modified  by  many  conditions,  for 
example,  general  diseases  causing  pronounced  anemia,  acute  diseases  causing 
toxins  and  other  abnormalities  in  the  blood,  heart  disease  causing  venous  conges- 
tion of  the  uterus,  acute  pelvic  inflammation  causing  arterial  congestion  of  the  uterus, 
tumors  and  malposition  causing  venous  congestion,  etc. 
Under  nutritive  changes  may  be  classed  the  following: 

Hyperemia  (arterial  arid  venous). 

Serous  infiltration. 

Hemorrhagic  infiltration. 

Disintegration  and  liquefaction. 

Hyperplasia. 

Hypertrophy. 

Atrophy. 

Obstruction  of  glands,  with  cystic  dilatation. 

Hyaline  degeneration. 


CLASSIFICATION  OF  THE  DISEASES  537 

The  inflammatory  changes  are  due  to  severe  local  irritation.  The  local  irrita- 
tion may  be  due  to  chemical  substances  (as  in  cauterization  of  the  endometrium 
with  penetrating  chemicals)  or  to  heat  (as  in  cauterization  by  steam)  or  to  invading 
cells  (as  in  cancer)  or  to  bacteria  and  their  products  (as  in  the  various  infectioas). 
Bacteria  and  their  products  constitute  by  far  the  most  frequent  cause.  In  in- 
flammation, the  nutrition  of  the  tissues  is  more  or  le.ss  disturbed  and  consequently 
there  may  occur  any  of  the  various  nutritive  changes  already  mentioned,  in 
addition  to  the  changes  distinctive  of  inflammation. 

The  inflammatory  changes  are  as  follows: 

Round-cell  infiltration    (leucocyte    infiltration    and    lymphocyte    in- 
filtration.) 
Connective-tissue  formation. 
Thrombosis. 
Necrosis. 

Abscess  formation. 
Sloughing. 

My  space  is  too  limited  to  accommodate  the  details  of  the.se  various  patholog- 
ical changes.  Each  change  mentioned,  however,  has  definite  characteristics  and 
significance,  which  will  be  found  elucidated  in  works  on  Pathology. 


CLASSIFICATION  OF   DISEASES. 

In  the  inflammatory  and  nutritive  diseases  of  the  uterus,  there  are  all  grada- 
tions in  pathological  conditions,  from  a  slight  nutritive  disturbance  in  a  uterus 
otherwise  normal,  to  the  terminal  stage — cirrhosis — which  represents  complete 
de.struction  of  the  uterus  as  a  functionating  organ.  The  process  is  progres.sive 
and  depends  on  two  factors — irritation  and  poor  nutrition,  usually  represented 
respectively  by  bacteria  and  inadequate  blood  supply.  One  or  the  other  of  these 
factors  is  always  present,  and  in  many  ca.ses  both  are  present,  the  character  of 
the  disease  depending  on  the  predominating  factor. 

Though  no  entirely  satisfactory  classification  of  the  inflammatory  and  nutritive 
diseases  of  the  uterus  has  yet  been  devised,  still  there  are  classifications  that  do 
very  well  for  practical  purposes.  The  following  cla.ssification  is  the  one  I  have 
found  most  convenient.  It  is  practical,  in  that  the  various  named  c-onditions  are 
as  a  rule  distinguishable  at  the  bedside,  and  the  names  are  sufficiently  distinct  and 
accurate  to  indicate  in  a  general  way  the  pathology  of  the  condition.'  nr.med. 

In  the  cervix  uteri  there  occur  the  following  inflammatory  and  nutritive  diseases: 

Erosion  of  cervix. 

Ulcer  of  cervix. 

Acute  Endocervicitis. 

Chronic  Endocervicitis. 

Laceration  of  cervix. 

Idiopathic  Hypertrophy  of  cervix. 

Polypi  of  cervix. 


538  DISEASES  OF  THE  UTERUS 

In  the  corpus  uteri  there  occur  the  following  inflammatory  and  nutritive  dis- 
eases: 

Acute  infected  Endometritis  and  Metritis. 
Acute  simple  Endometritis. 
Chronic  infected  Endometritis. 
Chronic  Simple  Endometritis. 
Subinvolution  of  uterus. 
Hj-perinvolution  of  uterus. 
Sclerosis  of  uterus. 
Tuberculosis  of  uterus. 
Sj'philis  of  uterus. 
Echinococcus  disease  oi  uterus. 

LOCALIZATION  OF  DISEASES. 

The  diseases  under  consideration  are  situated  in  various  parts  of  the  uterus. 
Some  of  them,  particularly  gonorrhoea!  and  septic  infection,  show  a  marked  ten- 
dency to  affect  all  portions  of  the  genital  tract — spreading  from  the  cervix  to  the 
endometrium  and  from  there  to  the  Fallopian  tubes  and  to  the  peritoneal .  cavity , 
and  also  through  the  wall  of  the  uterus  to  the  periuterine  connective  tissue  and  to 
the  peritoneum.  In  tubercular  infection  the  progTess  is  generally  downward,  the 
infection  spreacUng  from  the  Fallopian  tubes  to  the  endometrium.  Other  processes 
affect  the  whole  uterus  simultaneously,  though  in  varying  degi'ee,  for  example, 
subinvolution  following  labor  or  abortion.  Still  other  inflammatory  or  nutritive 
processes  are  localized  to  one  part  of  the  organ,  for  example,  erosion  (cervix), 
simple  endometritis  (endometrium). 

The  inflammatory  and  nutritive  diseases  are  localized  principally  as  follows: 

a.  Vaginal  surface  of  cervix.  This  is  the  seat  of  erosions  and  of  ulcers  of 
various  kinds. 

b.  Cervical  mucosa  and  adjacent  tissues.  Here  are  found  acute  endocervicitis 
(septic  and  gonorrhoealj,  chronic  endocervicitis  (septic,  gonorrhoea!  and  glandu- 
lar) and  cervical  poh-pi.  In  endocervicitis  the  process  is  not  confined  to  the 
cervical  mucosa  but  invades  the  adjacent  tissues  to  a  gi'eater  or  le.ss  extent,  hence 
it  is  sometimse  called  cervical  metritis,  signifying  that  the  cervix  as  a  whole  is 
involved.  But  the  process  starts  in  the  mucosa  and  the  principal  changes  are 
found  there,  consequently  I  think  the  term  "endocervicitis"  preferable. 

c.  Muscular  and  connective  tissue  of  the  cervical  wall.  Occasionally  an  acute 
inflammatory  process  is  principally  localized  here  and  may  result  in  an  abscess. 
Usually,  however,  the  changes  in  these  tissues  are  either  secondary  to  endocervi- 
citis,re.sultingin  cellular  infiltration  and  connective  tissue  formation  with  subsequent 
sclerosis,  or  the  changes  are  primarily  nutritive  in  character,  partaking  of  the 
nature  of  hyperplasia.  The  first  condition  (secondary  cellular  infiltration)  is 
found  accompanying  cystic  disease  and  all  inflammations  of  the  cervix,  particularly 
chionic  infected  endocervicitis.  The  second  condition  (hyperplasia)  is  found  in 
the  so-f-alled  "idiopathic  hypertrophy"  of  the  cervix. 

d.  Endometrium  and  adjacent  tissues.  Most  of  the  inflammatory  and  nutritive 
diseases  of  the  body  of  the  uterus  start  iu  the  endonietriuui.     On  account  of  the 


EROSION  OF  THE  CERVIX  539 

absence  of  a  submucous  connective-tissue  layer  in  the  uterus  (the  mucosa  being 
placed  directly  of  the  muscular  wall),  inflammatory  processes  starting  in  the  endo- 
metrium soon  affect  the  underlying  muscular  tissue,  the  depth  to  which  the  serous 
and  cellular  infiltration  extends  depending  on  the  severity  and  duration  of  the 
disturbance. 

The  endometrium  is  the  seat  of  acute  endometritis  (septic  or  gonorrhoeal),  of 
chronic  infected  endometritis  (septic  or  gonorrhoeal),  of  chronic  simple  endome- 
tritis (hypertrophic  or  atrophic),  and  of  tuVjerculosis. 

e.  Muscular  and  connective  tissue  of  the  corpus  uteri.  These  tissues,  as  previ- 
ously explained,  are  affected  in  practically  all  cases  of  endometritis,  but  only  sec- 
ondarily and  in  a  minor  way.  The  inflammatory  and  nutritive  affections  situated 
principally  in  these  tissues  are  acute  diffuse  metritis  (with  or  without  abscess 
formation),  cirrhosis  of  uterus  and  subinvolution. 

f.  Peritoneal  coat  of  uterus.  Those  diseases  affecting  principally  the  peritoneal 
layer  of  the  uterine  wall  are  considered  under  affections  of  the  pelvic  peritoneum, 
in  chapter  X,     They  are  peritonitis  and  tuberculosis  of  the  peritoneum. 


EROSION  OF  CERVIX. 

An  erosion  of  the  cervix  is  an  area  on  the  vaginal  surface  of  the  cervix  which  is 
covered  with  columnar  epithelium,  and  consequently  presents  a  reddened  in- 
flamed appearance.  Some  confusion  has  resulted  from  the  application  of  the  term 
"ulceration  of  cervix"  to  this  condition.  There  is  no  ulcer  and  no  granulating 
surface,  for  the  whole  area  is  still  covered  with  epithelium. 

Etiology  and  Pathology. 

The  erosion  is  caused  by  an  irritating  vaginal  or  uterine  discharge.  The  dis- 
charge may  originate  in  the  vagina  (e.  g.,  gonorrhoeal  vaginitis)  or  in  the  cervix 
(endocervicitis)  or  in  the  body  of  the  uterus  (endometritis).  Any  condition  that 
gives  rise  to  an  irritating  discharge  may  cause  an  erosion  of  the  cervix. 

The  reddened  appearance  seen  in  erosion  is  due  to  the  development  outside  of 
the  external  os  of  a  surface-covering  that  resembles  the  cervical  mucosa,  i.  e., 
there  is  but  one  layer  of  cells  and  they  are  columnar.  This  thin  epithelial  layer 
permits  the  underlying  vascular  tissue  to  show  through,  and  thus  gives  the  area  its 
red  appearance. 

On  microscopic  examination  the  red  patch  is  found  to  be  covered  with  a  single 
layer  of  columnar  epithehal  cells  (Fig.  551).  As  this  epithelial  layer  proliferates, 
however,  it  shows  a  marked  tendency  to  become  much  folded,  forming  deep  de- 
pressions and  tall  papillae,  a  condition  known  as  a  papillary  erosion.  Not  infre- 
quently the  tips  of  the  papillae  or  folds  become  adherent,  formingc  losed  cavities 
or  follicles  between  them,  which  become  filled  with  secretion  or  exudate.  This  is 
called  a  follicular  erosion. 

Just  why  this  columnar  epithelium  should  develop  on  a  surface  previously 
covered  with  squamous  epithelium,  is  not  positively  known.     It  is  generally  sup- 


540  DISEASES  OF  THE  UTERUS 

posed  to  be  due  principally  to  the  proliferation  or  outgrowth  of  the  mucosa  of 
the  cervical  canal  beyond  the  external  os,  the  proliferation  being  caused  by  one 
of  the  various  forms  of  irritation  previously  mentioned. 


\t 


UJ'- 


V 


Fig.  551.  Section  through  an  Erosion  of  the  Cervix.  At  the  right  is  the  normal  squamous  epithelium  covering 
the  vaginal  portion  of  the  cervix.  At  the  left  is  the  Area  of  Erosion,  showing  the  papillary  projections  covered 
with  a  single  layer  columnar  epithelium.  The  cavities  below  the  surface  are  gland  cavities  somewhat  dilated, 
showing  a  tendency  to  cyst  formation.     (A.  Ma.Ttin— Atlas  of  Gynecology.) 

Symptoms  and  Diagnosis. 

The  symptoms  due  to  the  erosion  are  usually  obscured  by  the  symptoms  of  the 
causative  lesion.  The  erosion  causes  some  increase  in  the  discharge.  The  cervix 
is  so  insensitive  that  but  httle  if  any  pain  results.  On  examination,  a  muco- 
purulent discharge  is  found.  When  the  cervix  is  exposed,  a  reddened  angry-looking 
area  is  seen  about  the  external  os,  extending  outward  irregularly  and  gradually 
shading  into  the  normal  covering  (Figs.  438,  439).  Though  the  lesion  is  super- 
ficial it  may  bleed  when  touched. 

The  lesions  which  may  be  confused  with  erosion  of  the  cervix  are  superficial  abra- 
sion, ulcer  of  cervix,  and  eversion  of  mucous  membrane. 

Superficial  abrasion  of  the  vaginal  portion  of  cervix  is  a  rather  rare  condition 
presenting  an  appearance  somewhat  like  an  erosion,  but  the  microscopic  appear- 
ance is  entirely  different.  Several  layers  of  the  epithelium  have  been  rubbed  off 
but  the  surface  is  still  covered  with  squamous  epithelium.  An  abrasion  is  usually 
due  to  mechanical  effect  (pressure  of  pessary  or  other  foreign  body)  and  does  not 
present  the  complicated  etiology  or  pathology  of  erosion.  It  usually  occurs  at 
the  point  where  the  pressure  comes  on  the  cervix  (from  pessary  or  other  body) 
and  not  especially  about  the  external  os,  as  does  the  erosion.  Its  outline  is  not 
so  well  marked  and  it  usually  disappears  rapidly  after  the  cause  is  removed. 

An  ULCER  of  the  cervix  presents  a  clear-cut  border,  sometimes  raised  and  indu- 
rated, and  the  base  of  the  ulcer  is  formed  by  granulation  issue.  The  different 
forms  of  ulcer  (simple,  chancroidal,  syphilitic,  tubercular,  malignant)  present  also 
special  characteristics,  which  will  be  given  later. 


ULCER  OF  THE  CERVIX  54] 

In  EVEHSION  OF  MUCOUS  MEMBRANE  from  laceration,  the  fact  that  the  cervix 
aas  been  Ulcerated  is  aj)parent,  and  close  examination  of  the  reddened  surface 
will  show  that  it  is  turned-out  endocervical  mucous  membrane.  An  erosion  of 
tiie  cervix  may  coexist  with  eversion,  in  fact,  the  combination  is  very  frequent, 
tiie  erosion  being  due  to  the  irritating  discharge  caused  by  the  laceration  and 
eversion. 

Treatment. 

1.  Remove  the  cause.  If  due  to  the  irritation  of  a  pessary,  the  pessary  must 
be  removed  for  a  time.  If  due  to  an  irritating  discharge  from  the  vagina  or  uterus, 
the  primary  lesion  (causing  the  discharge)  must  receive  appropriate  treatment. 

2.  Keep  the  vagina  clean  with  antiseptic  douches  taken  once  or  twice  or  three 
times  daily,  the  frequency  depending  on  the  amount  of  discharge. 

3.  Every  second  or  third  day  apply  some  antiseptic  astringent,  for  example, 
a  10^  solution  of  silver  nitrate  or  protargol  or  copper  sulphate,  and  then  dust  in 
an  antiseptic  astringent  powder  and  introduce  a  dry  tampoon  against  the  cervix. 
The  tampon  is  to  be  removed  the  next  morning  and  the  douches  continued  until 
the  next  office  treatment. 

ULCER  OF  CERVIX. 

An  ulcer  of  the  cervix  is  an  area  on  the  cervix  which  has  lost  its  epithelial 
covering  down  to  connective  tissue,  the  base  being  formed  by  granulation  tissue 
or  slough. 

The  causes  of  an  ulcer  of  the  cervix  are  simple  irritation  (as  from  a  pessary  or 
a  very  irritating  discharge  or  from  rubbing  of  the  clothing  when  the  uterus  is  pro- 
lapsed), chancroidal  infection,  syphilis,  tuberculosis,  and  mahgnant  disease. 

The  essential  pathology  is  stated  in  the  definition.  It  differs  from  an  erosion  in 
chat  there  is  a  distinct  break  in  the  epithelial  covering  of  the  cervix. 

Symptoms  and  Diagnosis. 

The  most  prominent  symptom  of  ulcer  of  the  cervix  is  vaginal  discharge,  which 
is  sometimes  streaked  with  blood.  When  the  cervix  is  exposed  with  the  speculum 
the  ulcer  on  its  surface  comes  into  view.  It  may  be  large  or  small,  superficial  or 
deep.     It  often  bleeds  when  touched. 

The  conditions  that  may  be  confounded  with  ulcer  of  the  cervix  are  erosion  of 
cervix  and  laceration  of  cervix  with  eversion  of  mucosa.  In  erosion  the  lesion  is 
very  superficial  and  usually  surrounds  the  external  os  and  the  whole  surface  is 
still  covered  with  epithelium.  The  cause  is  usually  apparent  and  there  is  no  raised 
clear-cut  border  nor  sunken  base.  In  laceration  of  cervix  with  eversion  of  mucosa, 
the  laceration  is  apparent,  and  by  clearing  all  secretion  from  the  reddened  sur- 
face and  examining  it  closely,  it  can  be  seen  that  it  is  mucous  membrane  and  not 
granulation  tissue. 

After  the  diagnosis  of  ulcer  is  established,  the  next  step  is  to  determine  what 
kind  of  an  ulcer  it  is.  A  rapidly  spreading  ulcer  with  undermined  or  punched- 
out  edges,  following  suspicious  intercourse,  is  probably  chancroidal.     A  chronic 


542  DISEASES  OF  THE  UTEI.US 

ulcer  resisting  treaxment  is  either  syphilitic,  tubejcular  or  malignant.  If  syphi- 
litic, there  will  be  other  evidences  of  syphilis.  If  tubercular,  scrapings  from  the 
surface  or  sections  of  tissue  will  show  tubercle  bacilli.  A  malignant  ulcer,  that  is, 
an  ulcer  due  to  the  breaking  down  of  malignant  infiltration,  usually  presents  a 
wide  area  of  infiltration  about  the  ulcerated  portion.  It  shows  also  a  decided 
tendency  to  bleed  and  the  bleeding  is  not  stopped  by  the  repeated  application  of 
10%  copper  sulphate  solution.  If  the  patient  is  aged,  that  increases  the  probab- 
bility  of  the  trouble  being  malignant.  Any  chronic  ulcer  resisting  treatment  with- 
out apparent  cause  (persistent  irritation,  syphilis  or  tuberculosis)  is  probably 
malignant,  and  should  have  a  piece  excised  for  microscopic  examination,  that 
malignant  disease  may  be  excluded  or  proven. 

Treatment. 

The  treatment  depends  of  course  on  the  character  of  the  ulcer? 

In  simple  ulcer.  If  due  to  a  pessary,  lemove  the  pessary  and  give  a  hot  anti- 
septic douche  two  or  three  times  daily,  depending  on  the  amoimt  of  discharge. 
Also  every  other  day  or  every  third  day,  introduce  the  speculum,  expose  the  ulcer, 
make  an  application  of  copper  sulphate  (10%)  or  some  other  astringent,  and  then 
dust  on  an  antiseptic  astringent  powder  and  introduce  a  tampon  to  hold  the 
powder  in  place  against  the  cervix.  The  tampon  is  to  be  removed  the  next  morn- 
ing and  the  douches  continued  until  the  next  office  treatment. 

A  chancroidal  ulcer  which  spreads  in  spite  of  the  measures  mentioned  under 
simple  ulcer,  should  be  cauterized  deeply  with  carbolic  acid  and  then  treated  the 
same  as  a  simple  ulcer. 

In  syphilitic  ulcer  the  patient  should  receive  constitutional  treatment.  The 
local  treatment  is  about  the  same  as  for  simple  ulcer. 

A  tubercular  ulcer  without  decided  tuberculosis  elsewhere,  should  be  excised  if 
its  situation  will  admit.  If  it  cannot  be  excised  it  should  be  thoroughly  curetted 
and  cauterized  deeply  with  carbolic  acid  or  nitric  acid  oi  lactic  acid  or  the  thermo- 
cautery. After  cauteiization,  the  treatment  is  the  same  as  for  simple  ulcer, 
except  that  the  use  of  iodoform  is  especially  indicated.  If  the  ulcer  extends 
some  distance  up  the  cervical  canal  or  is  associated  with  tuberculosis  of  the  endo- 
metrium or  Fallopian  tubes,  hysterectomy,  vaginal  or  abdominal,  is  indicated, 
provided  of  course  that  there  is  no  other  lesion  contra-indicating  such  a  course. 
At  the  same  time,  internal  antitubercular  remedies  are  indicated. 

If  the  ulcer  is  malignant  (carcinoma  or  sarcoma)  the  uterus  should  be  removed 
at  once. 

If  the  character  of  the  ulcer  is  doubtful,  and  remains  so  after  a  short  course  of 
treatment,  excise  a  piece  of  tissue  from  the  margin  of  the  ulcer  and  submit  it  to 
a  pathologist  for  microscopic  examination. 

ACUTE  ENDOCERVITIS. 

Acute  endocervicitis  is  a('ut(;  iiiflainuuition  of  the  lining  of  that  portion  of  the 
uterine  canal  lying  between  the  external  and  internal  os.  It  is  sometimes  called 
"acute  cervical  endometritis"  and  "cervical  metritis." 


ACUTE  ENDOCERVKUTlS  543 

Etiology  and  Pathology. 

Acute  endocervicitis  is  due  to  infection  with  the  s^onococcus  or  with  ordinary 
pus  germs.  In  gonorrlioeal  vaginitis,  tlie  infianmuition  frequently  extends  into 
the  cervix  and  may  remain  in  check  tliere  for  sometime.  If  in  a  case  of  gonorrh(Bal 
vaginitis  applications  are  made  within  a  healtliv  cervix,  gonorrh(ral  endocervicitis 
is  Ukely  to  result.  Some  authorities  hold  tiiat  gonorrhcral  endocervicitis  is  usually 
the  prhnary  lesion  and  that  the  vagina  is  infected  from  these.  This  probably  takes 
place  in  some  cases  but  it  is  hardly  to  be  considered  the  rule. 

OrtUnai'y  septic  endocervicitis  may  follow  labor  or  abortion,  but  then  it  is 
usually  overshadowed  by  the  more  serious  inflammation  in  the  body  of  the  uterus, 
i.  e.,  the  septic  endometritis. 

The  pathological  -changes  are  practically  the  same  whether  the  inflammation 
be  ordinary  septic  or  gonorrhoeal,  except  that  the  former  is  usually  accompanied 
by  mechanical  injuries  (cervical  lacerations).  The  changes  are  hyperemia  and 
swelling  of  the  mucosa,  serous  infiltration  and  round-cell  infiltration  (leucocyte 
and  lymphocyte),  with  increased  secretion. 

Symptoms  and  Diagnosis. 

The  principal  symptom  of  acute  endocervicitis  is  increased  discharge  from 
the  cervix  with  irritation  resulting  therefrom  (Figs.  436,  437).  The  cervical 
secretion  is  tenacious  and  stringy  and  resembles  the  white  of  an  egg  except 
that  it  is  less  fluid  and  more  jelly-like.  The  normal  cervical  secretion  is  alka- 
line. There  is  usually  considerable  erosion  about  the  external  os,  from  the  irri- 
tating discharge.  There  is  also  hyperemia  of  the  cervix  and  bleeding  on  slight 
manipulation.  The  patient  has  an  uneasy  sensation  of  weight  and  discomfort 
in  the  pelvis,  though  acute  endocervicitis  alone  rarely  causes  pain.  If  there  is 
much  pain  it  is  probably  due  to  some  other  trouble,  for  which  search  should  be 
made. 

Acute  endocervivitis  causes  but  little  trouble  in  diagnosis.  The  irritating  dis- 
charge from  the  external  os  shows  that  there  is  inflammation  above  that  point. 
The  short  duration  excludes  chronic  endocervicitis  and  malignant  trouble.  The 
absence  of  pain  and  of  tenderness  of  the  body  of  the  uterus  on  bimanual  examina- 
tion, and  the  absence  of  other  symptoms  of  endometritis,  shows  that  the  inflam- 
mation is  not  in  the  body  of  the  uterus,  consequently  it  must  be  in  the  cervix. 
When  the  cervical  mucosa  is  touched  with  the  sound  or  apphcator  it  may  bleed, 
showing  that  there  is  hyperemia  and  inflammation,  and  confirming  the  diagnosis 
perviously  reached  by  exclusion.  The  bleeding,  however,  is  not  a  prominent 
feature,  not  nearly  as  prominent  as  in  cancer  and  other  forms  of  ulcer.  In  endo- 
cervicitis, the  character  of  the  discharge,  which  is  markedly  tenacious,  indicates 
that  most  of  it  comes  from  the  cervical  glands.  Whether  or  not  it  is  gonorrheal 
may  be  determined  by  looking  for  evidences  of  gonon-hoea  elsewhere  (vagina, 
urethra,  vulvo-vaginal  glands)  and  by  examining  the  discharge  for  gonococci. 

Treatment. 

The  objects  of  treatment  in  a  case  of  acute  endocervicitis  are  three — (1)  to  pre- 
vent the  inflammation  from  spreading  to  the  mucous  membrane  of  the  body  of 


544  DISEASES  OF  THE  UTERUS 

the  uterus,  (2)  to  prevent  the  inflammation  from  extending  deeply  into  the  gland- 
ular structure  of  the  cervix  where  it  will  become  chronic  and  (3)  to  stop  the  irri- 
tating discharge  and  the  consequent  discomfort.  In  all  applications  and  other 
manipulations  in  acute  endocervicitis,  if  the  body  of  the  uterus  is  free  from  in- 
flammation, it  is  very  important  not  to  disturb  the  internal  os.  The  plan  of  treat- 
ment is  as  follows: 

1.  Apply  protargol  or  silver  nitrate  (4%  to  10%)  to  the  interior  of  the  cervix 
every  second  or  third  day.  If  the  patient  has  gonorrhoeal  vaginitis,  the  endo- 
cervical  application  is  of  course  made  at  the  same  time  that  the  vagnia  is  treated. 
A  thin  strip  of  gauze  saturated  with  the  desired  liquid  is  placed  in  the  cervix  and 
held  in  place  for  twenty-four  hours  by  a  glycerine  tampon.  The  tenacious  cervical 
mucus,  which  prevents  the  medicine  from  coming  in  direct  contact  with  the  mucosa, 
should  first  be  removed  with  the  forceps  or  cotton-wrapped  applicator  or  small 
curet.  A  weak  solution  of  Hquor  potassae  helps  in  clearing  out  this  mucus.  After 
the  endocervical  application,  a  tampon  soaked  in  boro-glyceride  or  in  ichthyol- 
glycerine  (10%)  should  be  placed  against  the  cervix.  If  a  strong  astringent 
application  is  desired,  tannic-acid-glycerine  (10%)  may  be  used  on  the  tampon. 

2.  If  the  external  os  is  not  open  sufficiently  to  give  good  drainage,  it  should  be 
opened  by  dilatation  or  incision.  If  the  whole  cervix  is  congested  and  swollen, 
multiple  punctures  with  the  point  of  a  history,  deep  enough  to  give  free  bleeding, 
is  beneficial. 

3.  Give  a  hot  antiseptic  vaginal  douche  (e.  g.  bichloride  douche)  every  six  to 
twelve  hours.  If  there  is  no  coincident  inflammation  of  the  vagina  an  astringent 
douche  solution  may  be  used,  such  as  the  alum  and  zinc  sulphate  douche. 

4.  The  patient  should  do  but  Httle  walking  and  should  keep  rather  quiet,  though 
it  is  not  necessary  to  go  to  bed. 

Other  applications  which  have  been  found  beneficial  are  formol,  25%,  tincture  of  io- 
dine, iodo-phenol,  carbolic  acid,  bichloride  solution  (1-500),  ichthyol  (pure),  ichthyol 
(25%)  in  glycerine  or  lanolin,  iodoform  in  ether  (saturated  solution),  iodoform 
and  tannic  acid  half  and  half.  Some  cases  yield  better  to  one  application  and  some 
to  another.  Skene  usually  used  a  mixture  of  tincture  of  iodine  two  parts  and 
carbolic  acid  one  part.  These  strong  applications  should  not  be  made  oftener  than 
every  five  to  seven  days.  The  application  may  be  made  with  a  cotton-wrapped 
applicator  dipped  into  the  solution  or  with  the  pipette,  by  which  a  small  amount 
of  the  desired  solution  is  placed  within  the  cervical  canal. 

Acute  endocervicitis  occurring  in  conjunction  with  acute  endometritis  is  over- 
shadowed by  the  latter  and  requires  little  or  no  separate  treatment. 


CHRONIC  ENDOCERVITIS. 

Chronic  endocervicitis  is  chronic  inflammation  of  the  cervical  mucosa  and  of  the 
tissues  adjacent  thereto.  It  is  known  also  as  "cervical  catarrh,"  "glandular 
endocervicitis,"  "cystic  disease,"  "cystic  degeneration,"  "glandular  degeneration," 
s*nd  "  jjiflammatory  hypertrophy." 


CHRONIC  ENDOCERVIcnTLS  545 

Etiology  and  Pathology. 

Chronic  gonorrhoea!  endocervicitis  and  chronic  septic  endocervicitis  usually 
l'()lk)W  acute  inHaninuition  of  Uke  character,  though  in  some  cases  the  acute  symp- 
toms are  so  slight  as  to  escape  notice. 

Laceration  of  tlie  cervix,  is  a  fruitful  source  of  chronic  endocervicitis,  often  with- 
out the  intervention  of  acute  inflammation  in  any  form.  The  cervical  glands  and 
lymph-spaces  are  torn  open  and  the  resulting  scar-tissue  obstructs  the  gland- 
ducts,  thus  leading  to  cystic  degeneration.  Laceration  als<j  causes  eversion 
of  the  mucosa  so  that  it  is  exposed  to  friction  against  the  vaginal  wall,  with 
consequent  chronic  inflammation.  Anything  that  causes  uterine  congestion 
tends   to   keep   up   the  endocervicitis. 

The  infecting  germs  penetrate  into  the  mucosa  of  the  cervix,  affecting  the  glands 
and  the  interglandular  tissue  and  causing  round-cell  infiltration.  There  is  increased 
secretion  from  the  cervix  and  the  discharge  is  irritating,  causing  erosion  of  the 
cervix  and  also  causing  vaginal  and  urethral  irritation.  The  cervix  is  enlarged 
and  chronically  congested,  and  eversion  of  the  mucosa  takes  place.  If  there  has 
been  laceration  with  eversion  of  mucosa,  the  chronic  inflammation  still  further 
everts  it.  When  there  has  been  no  cervical  laceration,  the  mucosa  may  still  be- 
come everted,  thus  enlarging  the  external  os  and  giving  the  appearance  of  lacera- 
tion. This  swelling  and  eversion  from  chronic  inflammation  without  laceration, 
may  take  place  in  the  virgin,  and  in  some  cases  has  given  rise  to  an  erroneous 
diagnosis  of  previous  pregnancy. 

In  chronic  endocervicitis  the  mucous  membrane  may  become  thickened  irreg- 
ularly, from  the  hyperplasia  and  round-cell  infiltration,  and  thus  form  papillary 
growths.  If  this  process  goes  on,  it  may  form  polypi  ("mucous  polypi,"  "cervical 
popypi").  If  the  external  os  is  so  small  that  theie  is  not  good  drainage,  the  se- 
cretion will  accumulate  in  the  cervical  canal  and  cause  dilatation  above  the  external 
os.     This  retention  of  irritating  material  may  cause  ulceration  within  the  cervix. 

The  gland-ducts  become  obstructed,  causing  the  glands  to  be  distended  into 
small  retention  cysts.  These  distended  glands  are  felt  as  hard  nodules  in  the  cervix 
and  may  give  rise  to  an  erroneous  diagnosis  of  cancer,  especially  when  associated 
with  severe  laceration.  The  cervix  may  be  honey-combed  with  these  small  cysts 
(Fig.  559),  producing  a  condition  designated  as  "  cystic  degeneration"  of  the  cervix. 
Sometimes  one  or  more  of  the  cysts  will  contain  pus  and  will  then  appear  as  a  yellow 
spot  on  the  cervix.  Occasionally  one  of  the  cysts  or  a  group  of  them  project  into 
the  canal  and  finally  become  pediculated,  forming  cervical  polypi.  Owing  to 
the  chronic  inflammation,  there  is  lymphocyte-infiltration  and  connective- tissue 
proliferation,  producing  enlargement  of  the  cervix — called  by  Emmet  "areolar 
hyperplasia."  Later  the  contraction  of  this  inflammatory  tissue  causes  more  or 
less  disintegration  of  the  other  tissue  elements  and  finally  the  cervix  passes  into  a 
condition  of  cirrhosis  or  sclerosis,  corresponding  to  the  same  process  in  the  body 
of  the  uterus,  which  is  known  as  sclerosis  or  interstitial  metritis. 

The  long-continued  irritation  of  chronic  endocervicitis  and  cystic  disease  is  prob- 
ably an  important  factor  in  the  causation  of  cancer  of  the  cervix. 


546  DISEASES  OF  THE  UTERUS 

Symptoms  and  Diagnosis. 

The  symptoms  of  chronic  endocervicitis  are  chronic  vaginal  discharge  and  erosion 

of  cervix.  Associated  with  these,  but  due  principally  to  accompanying  lesions 
(chronic  endometritis,  laceration  of  pelvic  floor,  pelvic  inflammation),  are  a  sense 
of  weight  and  dragging  in  the  pelvis,  backache,  and  pain  over  the  sacrum  (supposed 
to  be  the  seat  of  reflex  pain  from  the  cervix.) 

Chronic  endocervicitis  must  be  distinguished  from  chronic  endometritis,  lacer- 
ation of  cervix  and  cancer  of  cervix. 

In  chronic  endometritis  there  is  usually  a  history  of  pain  in  the  lower  abdomen 
and  some  menstrual  disturbance,  and  often  a  history  of  salpingitis.  Examination 
shows  the  uterus  somewhat  enlarged  and  tender.  A  complicating  salpingitis  is 
evidence  that  the  inflammation  has  involved  the  body  of  the  uterus  as  well  as  the 
cervix. 

In  CERVICAL  LACERATION,  the  cervix  loses  its  pyramidal  shape  and  the  edges  are 
turned  outward  and  the  mucous  membrane  is  everted  or  replaced  by  scar-tissue. 
The  cervix  is  broader  and  larger  than  normal  and  may  show  two  distinct  lips. 
The  extent  of  the  tear  can  usually  be  better  determined  by  the  sense  of  touch  than 
by  sight,  but  the  extent  of  the  eversion  of  the  mucosa  is  better  seen  than  felt. 
The  two  conditions,  chronic  endocervicitis  and  cervical  laceration,  are  often 
associated. 

In  BEGINNING  CANCER  of  the  cervix,  there  is  usually  an  areaof  in  duration. 
Also,  there  is  a  marked  tendency  to  bleed  on  manipulation  and  this  tendency  to 
bleed  is  not  removed  by  10%  copper  sulphate  apphcations.  Later,  the  discharge 
becomes  offensive  and  sanguino-purulent  and  contains  small  particles  (crumbly 
discharge),  but  the  diagnosis  should  be  made  before  these  marked  evidences 
develop,  as  it  may  be  too  late  then  to  effect  a  cure.  In  any  case  in  which  there 
is  a  suspicion  of  cancer,  a  small  piece  of  the  tissue  should  be  excised  for  microscopic 
examination  (see  page  86). 

Treatment. 

In  chronic  inflammation  of  the  cervix,  attention  to  the  patient's  general  health 
is  important.  Marked  anemia  and  lowered  vitality  from  any  cause,  may  pre- 
dispose to  chronic  endocervicitis  or  cause  it  to  persist.  Consequently,  if  such  con- 
ditions are  present,  appropriate  treatment  for  the  same  should  be  given.  Iron, 
quinine  and  arsenic  are  often  indicated.  The  uric  acid  diathesis,  or  Hthemia, 
is  prone  to  cause  persistence  of  chronic  cervical  inflammation.  Diseases  causing 
chronic  pelvic  congestion  are  especially  effective  in  the  same  direction,  hence 
measures  directed  toward  the  relief  of  pelvic  congestion  must  be  employed.  In 
all  cases  of  endocervicitis  the  most  important  step  in  treatment  is  to  remove  the 
cause  of  the  disease  when  that  is  possible.  Endometritis  or  malposition  of  the 
uterus  should  be  corrected  if  present  and  the  patient  should  be  put  on  a  regular 
tonic  regime. 

Locally  the  steps  in  treatment  recommended  for  acute  endocervicitis  ajre  indi- 
cated, and  also  the  following  additional  measures: 

1.  If  there  are  cysts,  puncture  and  evacuate  them  and  touch  the  cavities  with 


LACERATION  OF  THE  CERVIX  547 

some  antiseptic  astringent.  Cysts  projecting  into  the  canal  may  sometimes  be 
located  with  a  probe  or  tenaculum.  They  should  be  treated  the  same  as  those 
on  the  external  surface.  If  necessary  for  the  proper  treatment  the  canal  may  be 
dilated.  If  the  external  os  is  too  small  to  permit  of  good  drainage  or  satis- 
factory local  treatment,  it  should  be  opened  by  dilatation  or  incision.  The  con- 
tracted cervical  outlet,  or  "pinhole  os,"  is  rather  frequent  in  nullipara  and  causes 
retention  of  the  secretion  and  increased  irritation.  In  such  a  case  if  the  os  does 
not  yield  readily  to  dilatation  it  may  be  incised. 

It  is  sometimes  a  good  plan  to  curet  the  entire  cervical  canal  lightly  and  then 
apply  the  desired  medicine.  Strong  curettage,  however,  or  the  application  of  a 
strong  cauterant,  such  as  nitric  acid,  is  liable  to  cause  cicatricial  stenosis,  which 
later  requires  treatment  by  dilatation  or  incision. 

2.  If  there  is  considerable  laceration  of  the  cervix,  repair  it  as  previously  de- 
scribed. This  is  particularly  important  if  there  is  hypertrophy  or  cystic  disease. 
In  the  denudation  for  repair,  a  large  part  of  the  cystic  portion  may  be  excised. 

3.  If  the  cystic  disease  is  still  more  marked,  the  cervix  may  be  partially  am- 
putated by  Schroeder's  method  (Fig.  561).  This  operation  removes  the  cystic 
and  infiltrated  tissue  on  the  inner  side  of  the  cervical  lips  and  at  the  same  time 
preserves  the  outer  part  of  the  cervix,  which  is  comparatively  normal. 

LACERATION  OF  CERVIX  UTERI. 

Etiology. 

The  usual  cause  of  laceration  of  the  cervix  is  the  passage  of  the  head  and  shoul- 
ders of  the  child  in  labor.  The  cervix  will  stretch  wonderfully  when  softened  by 
pregnancy  and  slowly  dilated  by  the  bag  of  waters,  but  still  there  is  nearly 
always  some  laceration. 

In  operations  on  the  non-pregnant  uterus,  such  as  curetment,  the  cervix  is  oc- 
casionally torn  in  the  preliminary  dilatation. 

A  congenital  split  resembling  a  lateral  laceration  of  the  cervix  has,  in  a  few  in- 
stances, been  observed  in  the  new  born  infant.  This  congenital  notch  is  of  little 
importance  except  that  when  seen  in  the  adult  it  may  lead  to  an  erroneous  diag- 
nosis of  previous  pregnancy.  A  distinct  laceration  of  the  cervix  is  one  of  the 
strongest  proofs  of  previous  pregnancy  and  the  fact  that  a  congenital  notch  some- 
what resembling  a  laceration  may  occur,  is  of  medico-legal  importance. 

Pathology. 

The  tear  of  the  cervix  in  labor  usually  affects  both  sides  causing  a  bilateral 
laceration,  with  one  side  torn  deeper  than  the  other  (Figs.  336,  440).  Occasionally 
only  one  side  is  torn  giving  a  unilateral  ulceration  (Fig.  334,  440).  Sometimes  the 
cervix  is  torn  in  several  directions  giving  a  stellate  laceration  (Fig.  439).  Still 
another  variety  is  the  internal  laceration,  a  tear  not  extending  entirely  through 
the  wall.  ,^ 

Tears  of  the  cervix  are  of  all  grades  of  severity.  The  tear  may  be  very  slight, 
leaving,  after  some  weeks,  only  a  small  notch  or  depression  (Fig.  332) ,  or  it  may 


548  DISEASES  OF  THE  UTERUS 

be  very  deep,  even  extending  into  the  vaginal  and  pericervical  connective  tissue 
or  into  the  bladder.  In  the  deep  tears,  the  lips  may  fall  together  and  heal  fairly 
well  so  that  only  a  small  notch  is  left.  On  the  other  hand,  the  lips  may  fail  to  unit 
in  which  case  a  deep  notch  may  be  left  (Figs.  336,  440).  Occasionally  the  cervix 
heals  in  such  a  way  as  to  leave  a  fistula  from  the  cervical  canal  into  the  vagina 
(cervico- vaginal  fistula).  In  the  case  of  an  "internal  laceration"  the  cervix  may 
appear  to  be  simply  dilated.  It  is  open  or  patulous  and  the  examining  finger 
may,  in  some  cases,  be  introduced  as  far  as  the  internal  os.  In  this  form  of  tear, 
the  conical  shape  of  the  cervix  may  be  preserved  if  no  marked  inflammatory 
change  has  taken  place. 

In  the  ordinary  bilateral  laceration  which  fails  to  unite  there  is  eversion  of  the 
cervical  mucosa.  The  mucous  membrane  lining  the  cervix  is  turned  out  (Figs. 
336,  440)  and  is  irritated  by  rubbing  against  the  vaginal  wall.  The  irritation  of 
the  cervical  mucosa  causes  increased  secretion  from  the  cervical  glands  (Fig.  437). 
Infection  leads  to  endocervicitis,  acute  and  chronic,  and  this  inflammation  may 
bring  about  destruction  of  the  mucous  membrane,  which  is  then  replaced  by  scar- 
tissue.  The  rolling  out  of  the  lips  of  the  cervix  may  progress  to  such  an  extent 
that  the  notch  between  the  lips,  which  is  one  of  the  signs  of  laceration,  is  obliterated 
— so  that  the  cervix  appears  as  a  round  ball  (Fig.  552) . 

Frequently  there  is  much  scar  tissue  covering  the  inner  portions  of  the  cervical 
flaps,  and  a  thick  wedge  of  scar-tissue  in  the  angle  of  the  tear  on  each  side.  The 
ducts  of  the  cervical  glands  become  obstructed  by  the  inflammation  and  scar- 
tissue  contraction  and  small  cysts  are  thus  formed,  causing  nodules  in  the  cervix 
(Figs.  559,  560).  These  small  cysts  feel  like  shot  of  various  sizes  in  the  cervix. 
This  indurated  and  nodular  condition  may  lead  to  an  erroneous  diagnosis  of  ma- 
lignant infiltration.  If  these  nodules  be  punctured  and  then  pressed  upon,  a  thick 
glairy  mucus  is  extruded,  leaving  a  small  cavity.  In  some  cases,  the  cervix  is 
riddled  with  these  cysts,  a  condition  known  as  cystic  degeneration  or  cystic  disease 
of  the  cervix.  Subinvolution  of  the  uterus  is  a  secondary  result  of  laceration 
of  the  cervix.  The  uterus  remains  large  and  heavy  and  drags  on  its  supports. 
Another  secondary  change  is  hypertrophy  of  the  cervix  (Fig.  560).  Owing  to  the 
chronic  inflammation  and  chronic  congestion  and  the  cystic  disease,  the  cervix 
gradualh^  enlarges  and  becomes  heavy  and  sinks  downward  and  forward  in  the 
pelvis. 

In  some  cases,  however,  the  supposed  enlargement  and  elongation  is  only  an 
apparent  hypertrophy.  Even  in  the  cases  in  which  there  is  considerable  hyper- 
trophy it  appears  to  be  more  than  it  really  is.  This  deceptive  condition  is  due  to 
eversion  of  the  lacerated  portion  of  the  cervix  and  descent  of  the  uterus  and  redu- 
plication of  the  vaginal  wall.  That  this  is  the  trueconditionmay  beshown  by  put- 
ting the  patient  in  the  knee-chest  posture,  when  the  uterus  will  gi-avitate  out  of 
the  vagina  toward  the  abdominal  cavity  and  the  point  of  attachment  of  the  vaginal 
wall  to  the  cervix,  and  the  amount  of  cervix  below  that,  may  be  seen.  Another 
fact  brought  out  by  this  examination  in  the  knee-chest  posture  is  that  there  are 
many  cases  of  laceration  of  the  vaginal  vault  that  appear,  in  the  ordinary  examina- 
tion, to h)e  laceration  of  the  cervix  only.  Owing  to  thesinking  of  theuterus  a.nd  re- 
duplication of  the  vagina,  the  tear  appears  to  be  wholly  in  the  cervix.     When  tbe 


LACERATION  OF  THE  CERVIX  549 

patient  is  put  ih  the  Sims  posture,  or  better  still  the  knee-chest  posture,  It  is  seen 
that  the  tear  extends  past  the  cervix  and  involves  the  vaginal  vault.  In  either 
of  these  conditions,  trachelorrhaphy  and  not  amputation  is  the  proper   treatment. 

Still  another  effect  of  a  deep  cervical  laceration  and  the  chronic  irritation  re- 
sulting there  from,  is  the  predisposition  to  the  development  of  cancer  of  the  cervix. 
This  danger  is  apparently  doubted  by  some  authorities  but  it  is  a  real  danger 
and  must  be  kept  in  mind. 

Laceration  of  the  cervix  as  seen  several  months  or  years  after  the  injury  is  usually 
accompanied  by  one  or  more  complications,  such  as  chronic  endometritis,  retro- 
version, or  loss  of  support  in  the  pelvic  floor. 

Symptoms  and  Diagnosis. 

The  symptoms  depending  on  the  laceration  itself  and  on  the  resulting  subin- 
volution and  inflammation  are  numerous,  though  none  are  distinctly  charac- 
teristic of  cervical  laceration.  The  symptoms  are  nearly  all  due  to  the  complica- 
tions rather  than  to  the  tear  itself. 

There  is  usually  a  vaginal  discharge,  or  leucorrhoea,  due  both  to  the  cervical 
injury  and  the  accompanying  endometritis.  When  there  is  a  preponderance  of 
cervical  secretion  in  the  discharge,  it  is  jelly-like  and  sticky  and  may  be  pulled 
out  into  long  threads,  and  it  is  hard  to  detach  from   the  cervical  canal. 

Menstrual  disturbances  usually  accompany  laceration  of  the  cervix  but  they 
are  due  largely  to  the  subinvolution  and  endometritis.  They  consist  of  painful 
menstruation  and  increased  menstrual  flow. 

Backache  and  dragging  pains  in  the  pelvis  are  usually  present  in  severe  lacera- 
tion but  they,  like  the  menstrual  disturbances,  are  to  be  attributed  largely  to 
the  complications  such  as  laceration  of  pelvic  floor,  subinvolution,  endometritis, 
and  salpingitis. 

Dyspareunia  may  be  present  in  a  case  of  laceration  of  the  cervix  and  the  proba- 
bility of  its  occurrence  is  increased  if  retroversion  is  present. 

Sterility  may  be  caused  by  a  cervical  tear,  the  increased  secretion  retarding  the 
progress  of  the  spermatozoa  or  the  cicatrical  contraction  causing  stenosis.  Abor^ 
tion  occasionally  results  from  an  old  cervical  injury. 

Reflex  symptoms  in  distant  organs  are  sometimes  excited  by  cervical 
injury.  A  familiar  example  is  tb^  increased  nausea  and  vomiting  of  pregnancy, 
often  seen  in  cases  of  severe  laceration  and  irritation  about  the  cervix.  In  many 
of  these  cases  the  cervix  is  tender,  and  pressure  upon  it  excites  stomach  distress. 
In  most  of  such  cases  an  application  of  silver  nitrate  solution  (4%)  or  cocaine  so- 
lution (10%)  to  the  cervix  will  give  much  temporary  relief,  indicating  that  the 
trouble  is  reflex  from  the  sensitive  cervix.  Among  the  reflex  disturbances  some- 
times due  to  a  lacerated  cervix,  come  also  stomach  disturbances  in  the  non-preg- 
nant, persistent  neuralgia  and  headaches  (particularly  headache  at  the  vertex) 
and  a  general  nervous  irritability. 

The  reflex  influence  of  cervical  injuries  has  no  doubt  been  greatly  over-estimated 
by  some  writers,  and  affections  have  been  attributed  to  such  injuries  that  really 
had  no  connection  with  them  or  were  at  most  only  aggravated  by  them.      Lacera- 


550  DISEASES  OF  THE  UTERUS 

tion  of  the  cervix  is  frequently  accompanied  by  poor  general  health  which  may 
occasionally  be  due  to  the  local  and  reflex  disturbance  from  the  cervix,  but 
which  is  usually  due  to  some  complicating  disease. 

On  vaginal  examination  the  notch  in  the  cervix  may  be  distinctly  felt  and  also 
the  enlargement  and  the  cystic  condition  when  present.  If  there  is  a  deep  tear, 
the  anterior  and  posterior  lips  may  be  made  out.  When  the  cervix  is  exposed  to 
view  through  a  speculum  the  amount  of  eversion  of  the  mucous  membrane  may 
be  seen  and  also  any  area  of  erosion  caused  by  the  irritating  discharge.  The 
bivalve  speculum  may  distort  the  cervix  and  make  it  appear  somewhat  more 
widened  and  changed  in  shape  than  it  really  is.  This  slight  distortion,  which 
however  is  not  of  much  importance  ordinarily,  may  be  avoided  by  using  the  Sims 
posture  and  the  Sims  speculum. 

In  some  cases  the  flaps  have  rolled  outward  so  far  that  there  is  no  notch  or  dis- 
tinct flaps  to  be  seen.  The  cervix  appears  simply  as  a  round  ball  (Fig.  552) 
instead  of  showing  two  distinct  lips.  By  catching  each  side  of  such  a  cervix  with 
a  tenaculum-forceps,  near  the  point  that  was  formerly  the  external  os,  and  bringing 
these  points  together  (Figs.  441,  442),  it  may  be  seen  that  the  cervix  has  been 
torn  into  two  lips,  and  also  some  idea  may  be  gained  of  the  depth  of  the  tear  and 
the  appearance  of  the  cervix  when  repaired. 

Laceration  of  the  cervix  with  chronic  inflammation  must  be  distinguished 
from  the  following  conditions: 

a.  Erosion  of  the  cervix.  In  simple  erosion,  the  conical  shape  of  the  cervix  is 
preserved  (Fig.  439).  An  erosion  is  often  present  with  laceration  as  a  result  of 
the  irritating  discharge.  It  then  appears  around  the  everted  mucosa  as  an  ir- 
regular reddened  inflamed-looking  area. 

b.  Ulcer  of  cervix.  In  ulcer  without  laceration  the  conical  shape  of  the  cervix 
is  preserved.  Also,  an  ulcer  shows  destruction  of  the  epithelial  covering  and  has 
a  depressed  base  and  raised  margin. 

c.  Chronic  endocervicitis  without  laceration.  In  most  severe  cases  of  chronic 
endocervicitis,  there  has  been  laceration.  But  there  are  certain  cases  of  endocer- 
vicitis without  laceration,  in  which  the  mucosa  becomes  pushed  out  and  everted 
from  the  inflammatory  swelling,  and  the  condition  has  somewhat  the  appearance 
of  laceration.  Such  an  appearance  has  lead  to  an  erroneous  diagnosis  of  previous 
pregnancy.  In  these  cases  the  cervix  as  a  whole  preserves  its  conical  shape,  the 
principal  ditsurbance  being  about  the  external  os,  which  may  appear  as  a  slit 
instead  of  as  a  round  opening  and  may  be  surrounded  by  swollen  everted  mucosa. 

d.  Cancer  of  cervix.  Usually  the  differential  diagnosis  is  easy.  In  some  cases, 
however,  when  the  cervix  is  deeply  torn  and  nodular  from  cysts,  it  may  be  impos- 
sible to  exclude  cancer  without  a  microscopic  examination  of  an  excised  piece  from 
the  suspicious  area. 

With  a  lacerated  cervix  are  frequently  found  one  or  more  complications — 
chronic  endocervicitis  or  subinvolution  or  chronic  endometritis  or  retroversion 
or  prolapsus  uteri  or  chronic  salpingitis  or  chronic  pelvic  cellulitis  or  chronic 
oophoritis. 

All  the  lesions  present  in  a  case  should  be  determined  as  far  as  possible  before 


REPAIR  OF  THE  LACERATED  CERVIX 


551 


operative  treatment  is  undertaken,  for  some  of  tiiem  may  require  treatment  at  the 
{.ame  time. 

Treatment. 

A  laceration  of  the  cervix  does  not  necessarily  cause  symptoms  nor  require 
treatment.  It  is  only  when  accompanied  by  certain  conditions  or  complications, 
menti-oned  below,  that  it  requires  treatment.  The  treatment  for  a  lacerated  cervix 
is  repair. 

Trachelorrhaphy. 

The  operation  for  repair  of  a  lacerated  cervix  is  known  as  "trachelorrhaphy." 
It  was  devised  by  Emmet  and,  together  with  Emmet's  operation  for  repair  of  the 
pelvic  floor,  stands  as  a  representative  of  the  careful  study  given  to  pelvic  dis- 
eases by  that  splendid  clinician. 

Indications.  A  lacerated  cervix  when  examined  after  several  months  or  years, 
may  present  either  of  the  following  conditions: 

a.  A  small  notch  on  one  or  both  sides,  the  remainder  of  the  cervix  being  normal 
(Fig.  332).     Such  a  cervix  does  not  require  repair,  as  it  causes  no  symptoms. 

b.  A  deep  notch  on  one  or  both  sides,  the  lips  being  soft  and  of  normal  size  and 
without  irritation  (Fig.  334).  Such  a  cervix  does  not  ordinarily  cause  any  dis- 
turbance. Occasionally,  however,  the  scar-tissue  in  one  or  both  angles  causes 
local  tenderness  and  reflex  disturbance.  In  such  a  case  the  laceration  should  be 
repaired. 

c.  The  cervix  presents  large  infiltrated  lips,  with  everted  mucous  membrane, 
cystic  formation,  an  irritating  discharge  and  spots  of  erosion  (Figs.  439,  440). 
There  may  be  no  well-defined  flaps  or  lips,  simply  a  globular  appearance  of  the 
swollen  cervix  (Fig.  552)  with  a  sHt-like  os,  surrounded  by  an  irregular  area  of 
everted  mucosa,  gi-anulation  spots  and  scar-tissue,  the  whole  covered  more  or 
less  with  a  muco-purulent  discharge.  Such  a  cervix  should  be  repaired,  not  only 
on   account   of   the  troublesome    symp- 

tomes  rsulting  from  it  but  also  because 
it  predisposes  to  the  development  of 
cancer. 

I  wish  to  emphasize,  however,  that  the 
simple  fact  that  a  cervix  has  been  lacer- 
ated is  not  an  indication  for  operation. 
Operation  is  indicated  only  when  there 
are  troublesome  local  conditions  which 
other  measures  fail  to  relieve. 

Contra=indications.  The  contra-indica- 
tions  to  this  operation  are  the  same  as 
the  contra-indications  to  repair  of  the 
pelvic  floor  (see  chapter  v). 

Preparations.  The  preparations  for  the 
operation  may  be  divided  into  prepara- 
tion of  patient,  preparation  of  instru- 
ments and  dressings    and    preparation 


uJ 


Fig.  552.  A  Lacerated  Cervix  in  wliich  there  is 
so  much  eversioD  that  the  Cervix  appears  as  a  round 
ball.     (KeUy— Operative  Gynecology.) 


of    operator 
paration  of  the  patient  is  both  local  and  general. 


and   assistants.     The  pre= 
When  the  cervix  presents 


552 


DISEASES  OF  THE  UTERUS 


erosion  or  ulceration  or  cysts  or  marked  infiltration  or  a  purulent   discharge,   it 
should  be  subjected  to  preparatory  treatment  as  follows: 

a.  Give  a  hot  antiseptic  douche  two  or  three  times  daily. 

b.  Puncture  the  cysts  and  touch  the  ca^'ities  with  strong  silver  nitrate  solution. 
or  other  antiseptic. 

c.  When  there  is  marked  congestion  and  infiltration,  bleed  the  cer\'ix  by  multiple 
punctures  once  or  twice  weekly.  Draw  off  one  or  two  tablespoonfuls  of  blood  each 
time  and  follow  the  bleeding  by  a  tampon  soaked  in  boroglyceride  or  ichthyol- 
glycerine.  Direct  the  patient  to  remove  the  tampon  in  twelve  to  twent5"-four 
hours  and  then  continue  the  hot  douches  until  the  next  office  treatment.  By 
this  method  the  cer\dx  may,  in  the  course  of  a  few  weeks,  be  reduced  considerably 
in  size  and  put  in  much  better  condition  for  repair. 

d.  Treat  the  complications,  such  as  retroversion  and  endometritis. 

e.  Give  laxatives  and  tonics  as  necessary  to  put  the  patient  in  good  condition 
generally. 

f.  Before  operating  for  repair  of  the  cervix  the  patient  should  be  carefully  ex- 
amined, that    all    lesions  present    may  be  determined  and  taken  into  considera- 


Fig.  553.  Instruments  for  Repair  of  the  Cen-ix:  a.  Edebohl's  self-retaining  speculum,  to  which  the  required 
weight  is  attached  by  a  small  hook;  b,  right-angled  vaginal  retractor  (have  two);  c.  long  tenaculum-forceps 
(have  two);  d,  vaginal  dressing-forceps  for  sponging  (have  two);  e.  bistourj-;  f.  long  straight  scissors;  g,  long 
cun-ed  scissors;  h,  long  tLssue-forceps;  i,  hemostat -forceps  (have  eight);  j,  Sims'  needle-holder;  k,  number  2, 
20-day  catgut  (have  six  tubes)  and  silkworjn-gut  (have  eight  strands)  and  strong  cenix  needles  (have  four). 
These  needles  should  have  sharp  trocar-points,  so  as  to  easily  penetrate  the  hard  tissue  of  the  cer\-ix. 


tion  in  the  treatment  and  prognosis.  It  may  be  found  that  the  laceration  of  the 
cervix  is  only  a  small  part  of  the  patient's  trouble  and  that  her  principal  .'symptoms 
are  due  to  malposition  of  the  uterus  or  to  lo.ss  of  support  in  the  pelvic  floor- or  to 
endometritis  or  to  salpingitis  or  to  appendicitis  or  to  a  pelvic  tumor.     Many 


STEPS  IN  REPAIR  OF  THE  CERVIX 


553 


bitter  disappointments  and  so-called  failures  have  followed  this  operation,  and 
other  operations  also,  because  the  operation  was  expected  to  remove  symptoms 
that  were  really  not  dependent  on  the  lesion  attacked.  Such  a  mistake  may  be 
avoided  by  examining  the  patient  carefully,  and  giving  to  each  lesion  present  its 
due  importance  in  the  production  of  the  complex  clinical  picture. 

Another  reason  for  ascertaining  carefully  all  lesions  present  is  that  some  other 
lesions  may  be  corrected  at  the  same  time  that  the  cervix  is  repaired,  for  example, 
the  uterus  may  be  curetted  or  a  malposition  con-ected  or  the  pelvic  floor  repaired. 

In  preparing  for  the  operation  on  the  cervix  avoid  the  menstrual  flow  for  ten 
days    after  the    operation  —  the 
l^est  time  for  the  operation  being 
four  to  ten  days  after  menstrua- 
tion. 

The  antiseptic  preparation  of 
the  patient  is  the  same  as  for 
repair  of  pelvic  floor. 

The  preparation  of  instruments 
and  dressings  is  the  same  as  for 
Abdominal  Section.  The  instru- 
ments required  for  trachelorrha- 
phy are  showni  in  Fig.  553. 

The  preparation  of  the  operator 
and  assistants  is  the  same  as  for 
Abdominal  Section  (see  chapter 
xv),  except  that  the  use  of  rub- 
ber gloves  is  not  so  imperative. 

Steps  in  the  operation.  After 
the  patient  is  anesthetized  and 
brought  to  the  edge  of  the  table 
(Fig.  573)  and  the  vagina 
scrubbed  the  same  as  for  curet- 
ment  (Fig.  574) ,  then  proceed  by 
the  following  steps: 

1.  Make  a  careful  bimanual 
examination,    under    anesthesia, 

of  the  uterus  and  tubes  and  ovaries.  When  the  bimanual  examination  is  finished, 
introduce  the  self-retaining  speculum  and  expose  the  cervix  and  catch  it  with 
a  tenaculum-forceps. 

2.  If  chronic  endometritis  or  subinvolution  is  present,  curet  the  uterus.  When 
the  cervix  is  to  be  repaired  immediately  after  curetment,  no  gauze  need  be  placed 
in  the  uterus. 

3.  Outline,  by  incision  with  the  bistoury,the  area  to  be  denuded,  leaving  in  the 
center  of  each  lip  a  strip  about  a  third  of  an  inch  wide,  to  form  the  new  cervical 
canal  (Figs.  554,  557).  The  strip  of  tissue  to  be  left  should  be  wide  enough  so  that 
no  stricture  will  result,  after  the  healing  and  involution.  Watch  this  point  partic- 
ularly, as  some  stenosis,  requiring  dilatation,  sometimes  follows  trachelorrhaphy.  It 
is  a  good  plan  to  leave  the  strip  a  trifle  wider  at  the  external  os  (Fig.  557). 


Fig.  534-  Areas  for  Denudation  Outlined  by  incis- 
ion with  the  knife.  This  shows  also  the  Method  of  De- 
nuding with  the  scissors.     (Hirst— Diseases  of  Women.') 


554 


DISEASES  OF  THE  UTERUS 


The  area  of  denudation  should  include  all  the  area  of  everted  mucous  mem- 
brane and  scar-tissue,  and  should  extend  slightly  outward  on  the  vaginal  surface 
of  the  cervix  so  as  to  give  a  wide  surface  of  denudation  for  approximation. 

4.  Denude.  A  very  good  way  is  to  first  make  an  incision  deep  in  the  angle 
of  each  side  (Fig.  556).  This  should  extend  through  the  scar-tissue  into  healthy 
tissue.  Then  catch  the  lower  angle  of  the  strip  to  be  removed  from  one  side  of 
the  lower  lip  and,  while  holding  this  with  the  tissue  forceps,  clip  it  loose  with  the 
scissors,  straight  or  curved  as  preferred  (Fig.  554).  This  process  of  cutting  is 
continued  all  the  way  to  the  base  of  the  flap.  The  upper  part  of  the  same  side  of 
the  cervix  is  treated  the  same  way,  and  then  the  other  side  of  the  cervix.  Begin- 
ning below  diminishes  the  inconvenience  from  the  bleeding.  Special  care  should 
be  taken  to  remove  all  scar-tissue  from  the  angles.  Cysts  in  the  area  of  denuda- 
tion should  be  excised.  If  the  surfaces  are  brought  together  with  cysts  in  them, 
the  operation  is  liable  to  do  more  harm  than  good,  as  the  cysts  may  continue  to 


Fig.  555.  The  Area  of  Denudation 
outlined  on  a  Rough  Lacerated  Cervix. 
The  angles  of  the  tear  are  situated  near 
a  and  b.  The  mucosa  to  be  left  to  form 
the  new  cervical  canal,  lies  between  the 
lines  d-d'  and  c-c'.  (Thomas  and  Munde 
— Diseases  of  Women.) 


Fig.  556.  Incision  through  the  Scar-tissue 
at  the  angles  of  the  laceration.  (Kelly — 
Operative  Gynecology.) 


develop  in  their  buried  situation  and  produce  reflex  disturbances.  If  cystic  areas 
cannot  be  readily  excised  so  as  to  permit  of  good  approximation  for  trachelor- 
rhaphy, the  areas  of  cystic  degeneration  should  be  removed  by  Schroeder's  partial 
amputation,  explained  later. 

For  denuding,  some  prefer  a  knife,  some  a  straight  scissors  and  some  a  curved 
scissors.  The  ''hawk-bill"  scissors  of  Skene  are  very  convenient  for  biting  the 
scar- tissue  out  of  the  angles  of  the  tear. 

5.  Introduce  the  sutures.  After  the  denudation  is  complete,  the  cervix  is 
cleansed  with  the  antiseptic  solution,  and  then  the  sutures  are  passed.  The  first 
suture    is  introduced  at  the  uppei-  angle  of  the  wound,  as  shown  in  Fig.  557.     As 


STEPS  IN  REPAIR  OF  THE  CERVIX 


555 


each  suture  is  passed  its  ends  are  caught  in  a  hemostatic-forceps  and  held  out 
of  the  way.  The  next  suture  is  passed  I  to  }  of  an  inch  below  the  first,  and  so 
on  down  to  the  end,  as  many  as  are  needed  for  that  side.  The  sutures  on  the 
other  side  arc  then  passed 
in  the  same  m  a  n  n  e  r  . 
When  all  the  sutures  are 
in  place  the  cervix  is 
washed  off  with  the  anti- 
septic solution  and  all 
clots  are  carefully  spong- 
ed away  from  the  angles 
of  the  tear.  The  sutin-es 
are  then  tied,  beginning 
with  the  one  first  passed. 
All  the  sutures  of  one 
side  are  tied  and  then 
those  on  the  other  side 
(Fig.  558).  The  line  of 
approximation  is  then 
examined  to  see  if  any 
superficial  sutures  are 
needed.  Frequently  one 
or  two  superficial  sutures 
will  be  needed  to  secure 
accurate  approximation. 
The  sutures,  if  of  silk- 
worm-gut, are  then  cut 
long — about  an  inch  from 
the  knots.  If  the  silk- 
worm-gut ends  are  cut 
shorter  they  are  likely  to 
stick    the  vaginal   wall 

and  cause  irritation.     If  after  denudation   there    is  much  bleeding  from  the  de- 
nuded angle  of  the  tear,  the  suture  at  the  angle  may  be  tied  as  soon  as  passed. 

6.  Replace  the  uterus.  The  uterus  is 
necessarily  pulled  down  a  good  deal  dur- 
ing repair  of  the  cervix  and  the  fundus  may 
have  gone  backward.  After  the  cervix  is 
repaired  the  speculum  should  be  removed 
and  the  uterus  replaced  to  its  normal  posi- 
tion by  bimanual  manipulation  (Fig.  582). 
A  strip  of  antiseptic  gauze  is  then  packed 
lightly  into  the  vagina  and  the  vulva  is 
covered  with  a  sterile  dressing  of  cotton  or 
gauze,  held  in  ]ilace  by  a  T-bandage. 


Fig.  557.     Denudation  Completed  and  Sutures  Passed  on  one  side. 
(Kelly —  Operative  Gynecology.) 


Fig.  558.  Sutures  Tied  —  O  pe  ra  tion 
Completed.  (  K  e  1 1  j  —  Operritive  Cyne- 
rolor/t/.) 


In  this  operation,   for   keeping   the   field 
clear   of    b  1  o  o  d,  I    employ  sponging  with 


556  DISEASES  OF  THE  UTERUS 

cotton-balls  wrung  out  of  bichloride  solution  (1-5000)  and  held  in  long  forceps,, 
with  occasional  washing  out  with  the  hot  bichloride  solution.  If  preferred,  con- 
tinuous irrigation  may  be  employed,  with  occasional  sponging. 

For  suture  material  in  the  cervix,  I  prefer  silkworm-gut,  except  when  the  pelvic 
floor  is  to  be  repaired  at  the  same  time.  Then  an  absorbable  suture  is  desirable, 
and  chromicized  catgut  (that  will  last  twenty  days  in  the  tissues)  is  satis- 
factory. No  suture  is  advisable  here  that  will  not  remain  at  least  ten  days  in 
the  mucosa.  Even  when  the  pelvic  floor  and  cervix  are  repaired  simultaneously, 
it  is  often  just  as  well  to  use  silkworm-gut  in  the  cervix  and  leave  it  in  place  four 
to  six  weeks.  When  the  pelvic  floor  is  firmly  healed,  place  the  patient  in  the 
Sims  posture,  carefully  introduce  the  Sims  speculum  and  remove  the  cervical 
sutures. 

If  trachelorrhaphy  is  carried  out  in  the  dorsal  posture,  there  is  no  difficulty  in 
tying  the  sutures.  In  the  Sims  posture  there  may  be  considerable  difficulty, 
necessitating  the  use  of  perforated  shot  for  fastening  them. 

Silver  wire  is  good  suture  material  for  the  cervix,  but  it  is  no  better  than  silk- 
worm-gut and  is  decidedly  more  inconvenient  to  handle. 

Silk  is  poor  suture  material  for  the  cervix  for  it  soon  becomes  soaked  with  fluid 
and  permeated  by  bacteria,  and  acts  as  an  irritant  in  the  tissues. 

When  there  is  a  stellate  laceration,  the  expedient  to  be  adopted  depends  on  the 
situation  and  extent  of  the  lacerations.  If  the  principle  laceration  is  bilateral, 
the  other  being  slight  and  consequently  of  little  importance,  the  latter  may  be  dis- 
regarded. If  the  third  laceration  is  deep  and  close  to  one  of  the  lateral  tears,  the 
small  intervening  piece  of  tissue  may  be  excised  and  the  laceration  converted 
into  a  simple  bilateral  one,  which  is  repaired  in  the  usual  way.  When  the  third 
tear  is  deep  and  near  the  center  of  the  anterior  or  posterior  lip,  it  may  be  denuded 
and  repaired  first,  and  then  the  lateral  tears  repaired  as  usual.  Sometimes  in  a 
bilateral  laceration  there  is  a  marked  disproportion  between  the  lips,  one  lip  being 
much  larger  than  the  other,  making  accurate  approximation  impossible  by  the 
usual  means.  When  the  difference  is  not  marked  it  may  be  equalized  by  extend- 
ing the  angle  of  excision  into  the  longer  lip.  When  the  disproportion  is  marked, 
a  wedge-shaped  piece  may  be  excised  from  the  longer  lip  and  the  wound  closed, 
and  then  the  two  lips  approximated  by  the  ordinary  operation.  Another  method 
is  to  trim  down  the  large  lip  by  cutting  the  end  and  sides  and  inner  surface.  That 
of  course  leaves  no  mucous  lining  for  the  new  cervical  canal.  However,  an  extra 
width  of  lining  for  the  new  canal  is  left  on  the  other  lip  and  this  prevents  union 
of  the  surfaces  where  the  canal  should  be.  If  the  lips  are  greatly  hypertrophicd 
from  cystic  disease,  partial  amputation,  as  described  below,  is  preferable  to  trache- 
lorrhaphy. 

After=treatment.  The  genitals  should  ])e  kept  covered  with  a  large  sterile  dress- 
ing of  cotton  or  gauze.  Do  not  catheterize  the  patient  unless  there  should  be 
retention  of  uriue. 

A  bowel  movement  should  be  secuired  the  second  or  third  day,  and  daily  after 
that.  The  gauze  packing  may  be  left  in  two  days.  It  is  then  removed,  and  there- 
after a  hot  bichloride  douche  (1-5000)  given  once  or  twice  daily,  depending  on 
the  amount  of  discharge. 


PARTIAL  AMPUTATION  OF  THE  CERVIX  557 

After  the  first  week,  the  patient  may  l"»e  allowed  to  o;et  up  and  walk  about,  as 
rest  in  bed  after  the  first  few  days  is  not  necessary  for  the  healing  of  the  cervix. 
In  many  cases,  however,  it  is  best  to  keep  the  patient  in  bed  two  or  three  weeks 
for  the  benefit  of  associated  diseases.  In  "run-down,"  nervous  and  worn-out 
women,  this  combination  of  the  rest-cure  with  the  operation  is  of  gi-eat  benefit, 
and  in  some  of  them  the  rest  in  bed  with  good  nourishment  and  relief  from  care, 
probably  contributes  as  much  as  the  cervical  repair  to  the  improvement  attained. 

The  sutures  are  removed  in  two  weeks.  The  most  convenient  way  to  remove 
the  sutm-es  is  to  place  the  patient  in  the  Sims  posture,  introduce  the  Sims  speculum, 
expose  the  cervix,  catch  an  end  of  a  suture  with  forceps,  pull  it  down  until  the 
knot  comes  into  view  or  can  1)0  felt  with  the  point  of  the  scissors,  and  then  cut  the 
loop.  When  it  is  supposed  that  the  sutures  are  all  out,  remove  the  speculum, 
place  the  patient  in  the  dorsal  posture  and  make  a  digital  examination  to  see  if 
all  the  sutures  are  really  out.  A  suture  missed  by  inspection  is  easily  felt  in  the 
digital  palpation. 

Sexual  intercourse  should  be  postponed  till  six  weeks  after  the  sutures  are  re- 
moved. 

Failure  to  secure  the  desired  result  from  the  operation  may  be  due  to: 

1.  Want  of  necessary  preparatory  treatment. 

2.  Infection,  which  of  course  spoils  the  operation  and  may  lead  to  serious 
periuterine  inflammation. 

3.  '  Insufficient  removal  of  the  scar-tissue  in  the  angles,  or  the  leaving  of  cysts 
somewhere  in  the  area  of  denudation. 

4.  Too  much  encroachment  upon  the  area  left  for  the  cervical  canal,  causing 
subsequent  stenosis  with  retention  of  contents  and  dilitation  above  the  constricted 
area. 

5.  An  incomplete  diagnosis.  Trachelorrhaphy  will  not  reheve  the  symptoms 
of  lacerated  pelvic  floor,  prolapsus  uteri,  adherent  retroversion,  chronic  salpingitis 
or  the  various  other  diseases  that  may  exist  in  the  pelvis.  To  operate  for  a  lacer- 
ated cervix  without  a  thorough  examination  and  diagnosis,  as  is  done  in  some 
cases,  is  to  invite  failure  and  disappointment. 

The  physician  is  often  asked  if  the  cervix  will  not  tear  again  at  the  next  labor. 
It  may  and  it  may  not.  Very  frequently  it  does  not  tear  to  any  considerable 
extent.  A  cervix  which  has  been  repaired  will  dilate  better  and  be  less  liable  to 
an  injurious  tear  than  one  that  is  the  seat  of  cystic  disease  and  dense  scar-tissue. 

Partial  Amputation. 

When  many  small  cysts  have  formed  in  the  everted  and  infiltrated  surfaces  of 
the  cervix,  as  shown  in  Figs.  559  and  560,  excision  of  the  cystic  area  (partial 
amputation  of  the  cervix)  is  preferable  to  regular  trachelorrhaphy.  Of  course, 
when  there  are  only  a  few  cysts  they  may  be  removed  in  the  regular  denudation 
for  repair,  but  when  the  "cystic  degeneration"  is  extensive,  excision  of  the  whole 
cystic  area  is  advisable.  The  line  of  excision  is  made  superficial  or  deep,  as  neces- 
sary to  include  the  cystic  portion  of  the  cervix  (Figs.  560,  561). 

Steps  in  the  operation.    The  preparations  are  the  same  as  for  repair  oi  the  cervix 


558 


DISEASES  OF  THE  UTERUS 


and  the  same  instruments  are  required.  When  the  cervix  is  exposed  with  the 
specuhuii,  it  is  grasped  with  tanaculum-forceps,  one  being  fastened  in  the 
anterior  Up  and  the  other  in  the  posterior  Up.     The  cervix  is  then  spht  on   each 

„      ^  side,  sufficiently   to  per- 

„^-r\    A  mit  access  to  the  cystic 

-^^''-'^^'    *  area    of    each  hp    (i^ig. 

562- A).  In  a  deeply-lac- 
erated cervix  this  may 
not  be  needed.  An  incis- 
ion is  then  made  across 
the  inner  surface  of  the 
baseof  the  anterior  lip,  ex- 
tending through  the  dis- 
eased layer  (Fig.  562-B). 
An  incision  is  then  made 
across  the  front  margin 
of  the  anterior  lip  and 
is  continued  down  in  the 
cervical  tissue  to  the 
other  incision  just  men- 
tioned (Figs.  562-C,  561). 


Fig.  559.  Cross-section  of  a  Cendx  which  is  the  seat  of  "Cystic 
Degeneration."  a.  Dilated  gland-ca\'ities,  forming  small  cysts,  b.  The 
cervical  canal.     (Pryor,  after  Comil — Pelvic  Inflammation.) 


Fig  560  Representing  Cystic  Defeneration  of  the  Cen-ix. 
This  shows  also  a  line  marking  the  area  to  be  excised  in  partial 
amputation  for  cystic  disease.     (Dudley— Prortice  of  Gynecology.) 


Fig.  561.  Showing  the  line  to 
follow  in  Excision  of  the  Cystic 
Area— Called  also  "Partial  Ampu- 
tation" and  "Schroeder's  Opera- 
tion."     (TryoT— Gynecology.) 

The  tissues  lying  to  the 
inner  side  of  the  knife  are 
thus  removed,  and  a  similar 
procedure  is  carried  out  on 
the  posterior  lip.  Sutures 
are  then  passed  in  the  an- 
terior lip  as  shown  in  Figs. 


EXCISION  OF  THE  CYSTIC  AREA 


559 


Fig.  562,  PartLal  Amputation  of  the  Cendx  (Sciiroeder's  Operatioo).  A.  The  cervix  split  from  side  to  side 
so  as  to  allow  access  to  the  base  of  the  cystic  area.  B.  Making  the  incision  across  the  base  of  the  cystic  area  in 
the  anterior  lip.  In  the  posterior  lip  the  cystic  area  is  already  excised  and  some  sutures  pa.ssed.  C.  Excisin;; 
the  cystic  area  in  the  anterior  lip.  Also  trimming  the  posterior  lip  to  allow  of  better  approximation.  D.  Both 
cystic  areas  excised  and  the  tissues  trimmed  for  approximation.  This  shows  also  the  method  of  suturing.  (Prj'or 
—Gynecology.) 


560 


DISEASES  OF  THE  UTERUS 


Fig.  563.  Partial  Amputation 
of  the  Cervix.  Sutures  Tied. 
(Pryor— Pe?i.-ic  Inflammation.) 


561  and  562-D,  bending  the  raw  surface 
on  itself,  so  that  the  two  portions  are 
approximated  and  will  grow  together. 
Similar  sutures  are  passed  in  the  pos- 
terior lip.  Any  raw  surfaces  left  at  the 
sides  of  the  anterior  or  posterior  lips  are 
closed  by  suturing  (Fig.  563). 

This  operation  removes  most  of  the 
diseased  tissue  and  reduces  the  size  and 
weight  of  the  cervix.  At  the  same  time 
any  troublesome  scar-tissue  in  the  angles 
of  the  laceration  may  be  removed. 


IDIOPATHIC  HYPERTROPHY  OF  CERVIX. 

The  term  "idiopathic  hypertrophy"  of  the  cervix  is  applied  to  enlargement  of 
the  cervix  independent  of  laceration  and  the  resulting  inflammation.  As  this  form 
of  hypertrophy  results  principally  in  elongation  it  is  sometimes  spoken  of  as 
"elongation  of  cervix."     It  is  a  rare  affection. 

Etiology,  Pathology,  Diagnosis. 

The  cause  of  this  marked  increase  of  tissue  and  elongation  of  the  cervix  is 
not  definitely  known.  In  some  cases  of  prolapse  of  the  uterus,  the  vaginal  walls 
which  prolapse  at  the  same  time  drag  on  the  cervix  and  elongate  it,  but  not  to 
the  extent  here  contemplated.  It  may  occur  in  the  married  or  unmarried.  It 
occurs  oftenest  in  nuUipara.  It  is  held  by  some  that  masturbation  is  an  im- 
portant etiological  factor,  as  it  is  in  hypertrophy  of  the  labia  minora.  In  regartl 
to  age,  it  occurs  most  frequently  between  the  ages  of  fifteen  and  thiity-five. 

There  is  an  incieaseof  tissue  in  the  cervix  but  in  such  a  way  that  the  cervix 
is  greatly  increased  in  length  without  a  corresponding  increase  in  width.  If 
the  hypertrophy  takes  place  only  in  the  vaginal  portion  of  the  cervix,  it  presents 
the  condition  sho\^^l  in  Figs.  298  and  299,  the  long  cervix  projecting  along  the 
vagina  or  even  outside  of  the  vagina  a  considerable  distance.  The  body  of  the 
uterus  and  the  vaginal  walls  remain  in  approximately  normal  position.  If  the 
hypertrophy  is  confined  to  the  supravaginal  portion,  the  vaginal  walls,  both 
anterior  and  posterior,  are  pushed  doANnward  by  the  same,  as  in  prolapse  (Fig. 
300).  The  body  of  the  uterus,  however,  remains  in  about  the  normal  position. 
If  the  hypertrophy  is  confined  to  the  intermediate  portion,  the  anterior  wall 
and  the  base  of  the  bladder  will  be  pushed  down  as  in  prolape,  the  posterior 
wall  remaining  stationary  (Fig.  301).  Retroversion  of  the  uterus  and  more  or 
less  prolapse  are  usually  present  also,  and  are  caused  by  the  dragging  of  the 
heavy  cervix  and  the  vaginal  walls. 

The  patients  complain  of  tlragging  weight  in  the  pelvis  and  of  a  protrusion  at 
the  mouth  of  the  vagina.     There  may  be  menstrual  disturbance  and  leucorrhoea. 


REGULAR  AMPUTATION  OF  THE  CERVIX 


561 


Examination  reveals  a  mass  with  tlie  charaeteristics  pi-e\aously  mentioned. 
From  PROLAPSUS  U'hehi  it  is  tlisHnguished  by  the  body  of  the  uterus  being  in 
approximately  normal  position.  From  uterine  tumor  projecting  into  the  vagina, 
it  is  distinguished  by  its  form  and  by  its  central  cavity.  From  inversion  of  the 
uterus,  it  is  distinguished 
by  the  body  of  the  uterus 
being  in  about  the  normal 
position  and  by  its  central 
opening. 


Fig.  564.  Regular  Amputation  of 
the  Cervix.  Showing  the  Wedge- 
shaped  Lines  of  Excision.  (Skene — 
Diseases  of  Women .^ 


Fig.  566.  Regular  Amputation  of  the  Cervix. 
Excision  of  tissue  completed  and  Sutures  passed. 
(Skene — Diseases  of  Women.) 


Fig.  565.     Amputation    of    the  Cervix.     First  step- 
splitting  the  cervix.     (Skeae— Diseases  of  Women.) 


Treatment. 

The  treatment  is  amputation.  The 
preparations  for  amputation  and  the 
instruments  required,  are  the  same  as 
for  repair  of  the  cervix. 

Regular  Amputation  of  Cervix. 

In  this  operation  enough  of  the  cer- 
vix is  amputated  to  reduce  it  to  the 
normal  size.  The  preferable  method 
is  to  make  the  incision  in  the  form  of 
a  wedge,  as  shown  in  Fig.  564,  so  that 
the  surfaces  will  approximate  well  and 
unite  without 
excessive  scar 
f  ormati  on. 
This  is  f  r  e  - 
quently  desig-  'f,',\  f  ? 
nated  as  the  i\.. 
"  wedge-shap- 
ed" amputa- 
tion of  the 
cervix. 

Fig.  567.  Sutures  tied, 
operation  completed.  (Skene 
—  Diseases  of  Women.) 


562  DISEASES  OF  THE  UTERUS 

The  long  cervix  is  first  split  laterally  into  an  anterior  and  posterior  lip  (Fig. 
565) .  The  required  amount  of  tissue  is  then  removed,  as  shown  in  Fig.  566. 
The  sutures  are  then  introduced  (Fig.  566)  and  tied  (Fig.  567). 

The  after-treatment  is  the  same  as  for  trachelorrhaphy, 

CERVICAL  POLYPI. 

Cervical  polypi  is  the  term  applied  to  small  non-malignant  tumors  found  in  the 
cervix  uteri.  They  are  usually  simple  adenomata  of  the  cervical  mucosa  and 
hence  are  frequently  designated  as  "mucous  polypi."  Occasionally,  a  small 
fibromyoma  of  the  cervix  will  become  pediculated  and  project  from  the  cervix, 
constituting  a  polypus. 

The  principal  symptoms  are  bleeding  and  leucorrhoeal  discharge.  It  is  sur- 
prising what  troublesome  and  persistent  bleeding  will  sometimes  be  occasioned 
by  a  small  polypus  in  the  cervix. 

On  digital  examination,  the  small  polypus  may  often  be  felt  as  a  small  soft  mass 
projecting  from  the  cervix  or  obstructing  the  external  os  (Fig.  342) .  In  some  cases 
the  polypus  is  so  soft  that  it  is  not  noticed  on  palpation. 

In  the  examination  through  the  speculum,  the  polypus  is  seen  (when  low  enough 
in  the  canal)  as  a  small  rounded  red  mass,  projecting  from  the  external  os  or  iiUin-g 
the  OS. 

The  important  thing  in  the  diagnosis  is  to  distinguish  beginning  malignant 
disease  from  simple  polypus.  Not  infrequently  in  malignant  disease  of  the 
cervix  small  projections  form  within  the  cervical  canal  and  appear  at  the  external 
OS,  presenting  almost  the  same  appearance  as  the  simple  polypus.  Whenever 
there  is  the  least  doubt  as  to  the  nature  of  the  polypus,  it  should  after  removal 
be  submitted  to  microscopic  examination. 

The  treatment  is  removal.  The  little  mass  of  tissue  may  usually  be  gi'asped 
with  the  long  dressing-forceps  and  twisted  off.  An  astringent-antiseptic  appli- 
cation is  then  made,  and  a  tampon  or  vaginal  packing  applied.  If  there  is  much 
bleeding  it  is  well  to  pack  the  cervical  canal  firmly  with  antiseptic  gauze,  to  be 
removed  in   forty-eight  hours. 

ACUTE  INFECTED  ENDOMETRITIS. 

This  is  acute  inflammation  due  to  bacterial  invasion  of  the  endometrium  and 
adjacent  tissues  in  a  uterus  not  recently  pregnant.  Metritis  and  endometritis 
in  the  recently  pregnant  uterus  (puerperal  sepsis)  is  an  obstetrical  subject. 

Under  the  above  title  I  include  the  changes  taking  place  deeper  in  the  uterine 
wall  (metritis)  as  well  as  those  strictly  in  the  endometrium. 

Etiology  and  Pathology. 

This  is  usually  due  to  infection  with  the  gonococcus  as  ordinarly  this  is  the 
only  germ  that  will,  on  mere  contact,  implant  itself  and  grow  and  spread  upward, 
in  the    non-puerperal    genital  tract.     Gonorrhoea  involves  the  cervix  in  a  large 


PATHOUXIY  OF  ACUTE  INFECTED  ENDOMETRITIS  563 

proportion  of  the  cases  of  vaginal  gonorrhhoea.  Its  extension  upward  from 
the  cervix  to  the  endometrium  may  be  spontaneous  or  induced.  Spontane- 
ous extension  upward  may  take  place  immediately  following  the  infection 
of  the  cervical  mucosa  or  the  inflammation  may  remain  limited  to  the  cer- 
vix for  weeks  and  months,  with  the  possibility  of  the  extension  upward 
at  any  time.  During  or  immediately  following  the  menstrual  flow  is  the 
favorite  time  for  the  progress  upward  of  the  gonococci.  This  fact  can  in  many 
cases  be  clearly  shown  by  questioning  the  patient  closely  as  to  just 
when  the  first  evidences  of  endometrial  infection  appeared.  Induced  extension 
of  the  gonorrhoeal  infection  upward  may  be  caused  by  treatment  designed  to 
check  the  inflammation.  On  this  account,  in  all  local  treatment  of  gonorrhoeal 
endocervicitis,  gi-eat  €are  should  be  taken  to  avoid  the  immediate  vicinity  of 
the  internal  os.  Also,  sounding  of  the  uterus  or  other  intra-uterine  instrumen- 
tation in  cases  of  gonorrhoea  of  the  cervix  (acute,  chronic  or  latent),  is  likely  to 
lead  to  gonorrhoeal  infection  of  the  endometrium.  Infection  of  the  endometrium 
with  other  inflammatory  bacteria  (staphylococcus,  streptococcus,  colon  bacillus, 
etc.)  is  usually  due  to  examination  with  a  sound  in  the  uterus  or  other  intra- 
uterine instrumentation,  the  germs  being  carried  in  from  outside  the  body  or  from 
the  vagina  or  from  the  cervical  canal.  Endometritis  so  caused,  was  rather  fre- 
quent formerly,  when  the  uterine  sound  was  passed  by  touch,  but  not  so  now  since 
the  uterus  is  not  so  often  sounded,  and  when  it  is  sounded  care  is  taken  to  do 
the  sounding  in  an  aseptic  way.  Still,  in  some  cases  infectious  germs  lurk 
in  the  cervix  without  decided  symptoms,  and  in  spite  of  precautions  the 
endometrium  may  be  infected. 

Occasionally  the  ordinary  pus  germs  may  extend  upward  in  a  pathological 
discharge  (due  to  chronic  endometritis).  In  this  way  a  simple  endometritis 
may  eventuate  in  an  infected  endometritis,  without  the  intervention  of  pregnancy 
or  instrumentation.  This  is  probably  a  rare  occurrence  in  the  presence  of  normal 
functional  activity  and  normal  tissue  resistance.  The  period  of  the  menopause, 
however,  with  its  nutritive  disturbance  and  its  diminished  tissue  resistance,  seems 
to  offer  exceptional  facilities  for  the  spontaneous  extension  upward  of  ordinary 
pus  germs.  Hence,  the  form  of  acute  endometritis  so  comparatively  frequent 
in  the  aged,  and  producing  such  special  conditions  (due  to  the  senile  condition  of 
the  tissues)  that  it  has  been  given  the  special  name  "senile  endometritis."  Senile 
endometritis  may,  as  explained  later,  be  either  simple  or  infected,  and  on  account 
of  the  senile  lowering  of  resistance  a  simple  endometritis  is  likely  to  become  an 
infected  one  by  spontaneous  extension  upward  of  pus  germs. 

Practically  the  whole  endometrium  is  evolved.  The  germs  lie  on  the  surface 
and  also  penetrate  into  the  glands  and  into  the  interglandular  tissue.  Later, 
they  penetrate  into  the  underlying  muscular  tissue  to  a  greater  or  less  extent. 
There  are  the  usual  phenomena  of  inflammation,  congestion,  swelling,  serous  and 
cellular  infiltration  into  the  tissues,  and  a  muco-purulent  discharge  consisting  of 
glandular  secretion,  serous  exudate,  dead  leucocytes  and  exfoliated  epithelium, 
with  occasionally  some  blood.  There  is  a  marked  tendency  of  the  infection  to 
spread  to  the  Fallopian  tubes. 


564  DISEASES  OF  THE  UTERUS 

Symptoms  and  Diagnosis. 

In  the  gonorrhoeal  cases,  after  the  vaginitis  or  cervicitis  has  continued  a  few 
days  or  several  weeks,  as  the  ca.se  may  be,  the  patient  complains  of  "cramps" 
in  the  lower  abdomen  and  of  soreness  in  the  pelvis  when  walking,  and  of  increased 
vaginal  discharge.  Sometimes  the  pain  is  quite  severe  and  occasionally  the  patient 
is  confined  to  bed  for  a  few  davs.  There  may  be  moderate  fever  (101  to  102), 
but  the  fever  is  rarely  marked  as  in  puerperal  endometritis.  By  close  questioning, 
we  can  usually  obtain  a  history  of  symptoms  indicating  gonorrhoea  within  the  last 
few  weeks  or  months. 

In  the  form  due  to  ordinary  pus  germs,  the  symptoms  are  about  the  same, 
with  a  history  of  some  local  treatment  (intra-uterine  instrumentation)  or  of  simple 
endometritis,  causing  discharge,  in  which  the  germs  multiplied  and  thus  extended 
upward.  If  there  is  any  discharge  from  the  urethra  or  vulvo-vaginal  glands, 
a  spread-preparation  of  it  is  made  on  a  cover-glass  or  slide,  which  can  later  be 
stained  and  examined  for  the  gonococcus. 

Digital  and  bimanual  examination  show  that  the  body  of  the  uterus  is  tender 
on  pressure.  If  the  disease  is  still  limited  to  the  uterus,  there  will  be  no  decided 
tenderness  outside  the  organ.  If  the  trouble  has  extended  to  the  adnexa,  there 
will  be  marked  tenderness  and  perhaps  a  mass  about  the  tube  involved.  Through 
the  speculum,  the  muco-purulent  discharge  may  be  seen  coming  from  the  cervix. 
Also,  the  condition  of  the  vaginal  walls,  as  to  whether  or  not  they  are  still  inflamed 
may  be  thus  determined. 

The  diagnosis  of  acute  endometritis  rests  upon  the  following  points: 

1.  Subjective  symptoms.  Moderate  pain  and  tenderness  of  recent  origin,  in  the 
lower  abdomen,  with  vaginal  discharge  and  some  fever. 

2.  Tenderness  of  body  of  uterus  on  bimanual  examination. 

3.  Muco-purulent  discharge  coming  from  the  uterus,  as  shown  by  speculum 
examination. 

4.  Absence  of  other  evident  lesion  to  account  for  symptoms.  Corroborative 
of  this  diagnosis,  is  a  history  of  recent  vaginal  inflammation  or  objective  evidence 
of  the  same  or  of  inflammation  of  the  urethra  or  vulvo-vaginal  glands  or  cervix. 
The  diseases  that  cause  confusion  in  diagnosis  are  :  acute  vaginitis,  acute  endo- 
cervicitis,  acute  pelvic  inflammation  and  hemorrhage  in  the  pelvis. 

In  ACUTE  VAGINITIS,  there  is  little  or  no  pain  or  tenderness  in  the  lower  abdo- 
men, the  uterus  is  not  particularly  tender  on  bimanual  examination  (the  tender- 
ness being  in  the  vaginal  walls),  and  speculum  examination  shows  enough  inflam- 
mation of  vaginal  walls  to  account  for  the  symptoms  (soreness  and  discharge). 

In  ACUTE  ENDOCERViciTis,  there  is  little  or  no  tenderness  in  lower  abdomen, 
the  body  of  uterus  '  is  not  particularly  tender  on  bimanual  examination  and 
speculum  examination  shows  a  profuse  glairy  discharge  from  the  cervix. 

In  ACUTE  PELVIC  iNFLAivLvi ATiON,  the  pain  is  more  constant  and  sharp  and  ex- 
tends more  into  the  sides.  Bimanual  examination  shows  that  the  tenderness  is 
situated  about  the  adnexa  of  one  or  both  sides,  instead  of  in  the  body  of  the 
uterus.  Also,  there  is  usually  some  indication  of  a  mass  of  exudate  to  one  side 
of  the  uterus. 


TREATMENT  OF  ACUTE  INFECTED  ENDOMETRITIS  565 

Of  course,  any  one  of  the  three  diseases  just  mentioned,  may  be  found  with  an 
acute  endometritis  and  then  the  symptoms  will  be  intermingled.  After  having 
established  the  fact  that  the  patient  has  an  acute  endometritis,  the  next  thing  to 
do  is  to  decide,  if  practicable,  what  kind  of  an  endometritis  it  is — whether  gonor- 
rhoeal  or  ordinary.  If  we  can  find  nothing  to  indicate  that  the  trouble  is  gonor- 
rhoeal,  we  assume  that  it  is  caused  by  the  ordinary  pus  germs.  In  questioning 
the  patient  as  to  evidence  of  gonorrhoea,  it  is  well  in  all  but  exceptional  cases  to 
avoid  arousing  her  suspicions  that  the  trouble  may  be  such.  Such  suspicion  on 
her  part  will  do  no  good  and  may  do  much  harm. 

The  points  indicating  that  the  trouble  is  gonorrheal  are: 

a.  History  pointing  to  recent  gonorrheoa,  particularly  symptoms  pointing  to 
acute  vaginitis  and  metritis  without  other  cause. 

b.  EA'idences  of  previous  inflammation  of  urethra  (redness  and  pouting-out 
of  m-ethral  mucous  membrane  at  meatus  and  tenderness  about  urethra)  or  previ- 
ous inflammation  of  a  vulvo-vaginal  gland  (redness  about  opening,  discharge  from 
duct  and  induration  and  tenderness  of  gland). 

c.  Acute  or  chrojiic  endocervicitis  without  other  cause. 

d.  Gonococci  found  in  discharge  from  urethra  or  vulvo-vaginal  glands  or 
cervix  or  endometrium. 

e.  Trouble  coming  on  shortly  after  man-iage  without  apparent  cause. 

f.  In  doubtful  cases  it  is  well  to  send  for  the  husband  (without  the  wife  know- 
ing it)  and  ascertain  from  him  if  he  has  any  evidence  of  gonorrhoea,  new  or  old. 

TREATMENT. 

No  abortive  or  quickly  curative  treatment  for  gonorrhoeal  or  other  acute  forms 
of  endometritis  has  been  found.  There  is  no  probability  of  immediately  danger- 
ous absorption  from  the  uterus  (as  in  puerperal  endometritis),  but  there  is  great 
probability  of  the  inflammation  becoming  chronic  and  persisting  for  months  or 
years,  and  sooner  or  later  involving  the  tubes.  In  many  cases  tubal  complica- 
tions develop  in  spite  of  the  most  careful  treatment,  though  the  treatment  un- 
doubtedly helps  to  prevent  such  complications  in  other  cases.  The  principal 
factor  in  preventing  the  bacterial  invasion  is  the  resisting  power  of  the  tissues. 
The  treatment  should  be  of  such  character  as  to  increase  this  tissue  resistance 
and  at  the  same  time  lessen  the  irritation  in  and  about  the  infected  uterus. 

General  measures.  The  pelvic  congestion  and  the  pain  should  be  relieved  as 
far  as  possible  by  general  measures.  The  patient  should  be  put  to  bed,  if  she  is 
not  there  already,  and  kept  in  bed  until  the  acute  symptoms  subside.  Open  the 
bowels  well  by  some  reliable  purgative  and  then  maintain  one  or  two  movements 
daily  by  a  laxative,  for  example,  one  or  two  teaspoonfuls  of  Rochelle  salt  each 
morning  in  a  glass  of  water  one  hour  before  breakfast.  Enemata  should  be  avoided 
in  gonorrhoea  an  account  of  the  danger  of  carrying  the  infection  into  the  rectum. 
If  there  is  much  pain  in  the  lower  abdomen,  use  hot  stupes  or  the  hot-water  bag. 
If  this  does  not  give  relief,  use  the  ice  bag.  If  the  pain  is  still  troublesome  or  if 
the  patient  is  restless,  give  mild  sedatives  internally. 

Vaginal  douches  and  applications.    The  hot  vaginal  douche,  given  according 


566  DISEASES  OF  THE  UTERUS 

to  the  special  directions  in  chapter  iii,  clears  the  irritating  discharge  from  the 
vagina  and  diminishes  the  pelvic  soreness.  It  should  be  a  weak  antiseptic  solu- 
tion, the  same  as  recommended  in  gonorrhoeal  vaginitis.  The  length  of  the  inter- 
val betewen  douches  will  depend  on  the  amount  of  remaining  vaginitis  and  the 
amount  of  uterine  discharge.  Ordinarily,  if  the  vaginal  inflammation  has  about 
disappeared,  every  six  hours  will  be  often  enough  for  the  vaginal  douche.  If 
there  is  still  decided  vaginitis,  the  silver  nitrate  or  protargol  apphcation  and  other 
measures  for  gonorrhoeal  vaginitis  are  indicated. 

No  intra-uterine  treatment  is  advisable  in  acute  non-puerperal  endometritis, 
whether  gonorrhoeal  or  otherwise.  Many  kinds  of  intra-uterine  treatment  have 
been  tried — intra-uterine  irrigation,  intra-uterine  applications  (weak,  strong  and 
medium),  intra-uterine  packings  (medicated  and  unmedicated  for  drainage), 
caustics  and  curetment — and  all  apparently  increase  rather  than  diminish 
the  chance  of  extension  upward,  which  is  the  great  danger.  If  it  is  apparent  that 
the  uterine  cavity  is  not  draining,  i.  e.,  that  there  is  retention  of  pus  within,  then 
'the  cervical  canal  should  be  dilated  sufficiently  and  a  small  rubber  tube  inserted 
for  drainage.  It  should  be  arranged  so  that  it  will  not  slip  out,  for  it  is  important 
that  the  drainage  be  free  and  constant.  With  free  drainage  and  the  carrying-out 
of  the  other  measures  mentioned,  we  have  assisted  nature  to  the  full  extent  of  our 
ability  in  preventing  extension  upward  to  the  tube  or  outward  through  the  uterine 
wall  to  the  parametrium.  Free  drainage  removes  the  pus  as  formed,  and,  as 
already  explained,  the  use  of  any  intra-uterine  instrument  whatever  is  likely  to 
stir  up  irritation  and  increase  penetration  of  bacteria  and  do  more  harm  than 
it  can  do  good.  The  use  of  soft  suppositories  containing  a  suitable  antiseptic 
may  eventually  prove  of  real  benefit  in  these  cases  (see  page  349). 

ACUTE  SIMPLE  ENDOMETRITIS. 

This  term  is  applied  to  certain  acute  changes  resembling  acute  inflammation 
that  appear  in  the  uterine  mucosa  without  bacterial  invasion. 

Etiology,  Pathology,  Symptoms. 

This  is  a  nutritive  change  and  is  due  to  pronounced  acute  congestion  of  the 
uterine  mucosa,  which  is  usually  due  to  some  acute  disease  such  as  pneumonia  or 
typhoid  fever  or  scarlet  fever  or  to  some  severe  shock  to  the  nerves  of  the  skin, 
as  by  an  extensive  Ijurn  or  prolonged  exposure  to  the  cold  or  heat,  or  to  suppression 
of  the  menses.  Because  of  its  frequent  association  with  some  of  the  exanthematous 
diseases  it  is  sometimes  called  "exanthematous  endometritis." 

In  some  cases  of  the  affection  mentioned,  there  is  intense  congestion  of  the 
uterine  mucosa,,  swelling  of  the  tissues,  serous  or  cellular  exudate  on  the  surface 
and  out  into  the  tissues,  exfoliation  of  the  cells  on  the  surface  and  in  the  glands, 
and  hemorrhage  onto  the  surface  and  into  the  tissues. 

The  trouble  is  primarily  uterine  congestion,  but  sometimes  the  changes  men- 
tioned persist  long  after  the  congestion  has  subsided.  The  process  may  be  ac- 
companied with  increased  discharge,  much  pain  and  the  usual  symptoms  of  mild 
acute  endometritis.     This  affection  is  rare  but  it  is  important  as  indicating  that 


PATHOLOGY  OV  CHRONIC  IXFECTED  ENDOMETRITIS  567 

symptoms    of   acute    infiainmatioii    may    l)o    present  without  infection  —  .dimply 
as  a  congestive  and  nutritive  change. 

Treatment. 

The  treatment  is  to  keep  the  patient  quiet,  remove  the  causative  affection  as 
far  as  possible,  reUeve  the  pelvic  congestion  by  purgatives,  and  give  vaginal 
douches  if  there  is  troul)lesome  discharge.  If  the  trouljle  is  due  to  suppression 
of  the  menses,  hot  sitz-baths  and  hot  applications  and  hot  douches  are  indicated, 
as  described  in  chapter  xiv.  Sedatives  should  be  given  as  required  to  relieve 
pain.  It  is  important  to  avoid  all  intra-uterine  instrumentation,  for  the  condition 
of  the  interior  of  the  uterus  favors  infection.  If  the  patient's  general  health  is 
restored,  the  disturbed  endometrium  usually  takes  care  of  itself,  the  damaged  cells 
being  cast  off  and  normal  conditions  restored.  Occasionally  some  source  of  intra- 
uterine irritation  may  remain  and  cause  a  chronic  simple  endometritis, 

CHRONIC  INFECTED  ENDOMETRITIS. 

This  is  chronic  inflammation  of  the  uterus  due  to  bacterial  invasion.  The 
different  germs  have  been  mentioned  when  speaking  of  the  various  forms  of  the 
acute  stage  of  bacterial  invasion  of  the  uterus.  Chronic  infected  endometritis  is 
known  in  its  various  forms  as:  chronic  endometritis,  chronic  metritis,  chronic 
catarrh  of  uterus,  chronic  gonorrhoeal  endometritis  and  chronic  septic  endo- 
metritis. 

Etiology  and  Pathology. 

Chronic  infected  endometritis  follows  acute  infected  endometritis  (either  gonor- 
rhoeal or  septic).  In  some  of  the  cases  of  acute  inflammation  of  the  uterus,  the 
process  does  not  disappear  after  the  acute  symptoms  subside  but  remains  for 
months  and  years,  causing  troublesome  leucorrhoea  and  menstrual  disturbances. 

In  the  uterine  tissues  the  serous  infiltration  of  the  acute  inflammation  is  largely 
absorbed,  but  the  cellular  infiltration  remains  to  a  considerable  extent  and  there 
is  connective  tissue  formation.  The  germs  keep  up  a  constant  irritation  in  the 
tissues,  leading  to  chronic  hyperemia  of  the  endometrium  and  adjacent  tissues. 
This  chronic  irritation  and  the  increased  blood  supply  causes  hyperplasia  of  all 
the  tissue  elements.  The  cellular  infiltration  combined  with  the  hyperplasia  of 
the  fixed  tissue  elements  causes  thickening  of  the  endometrium.  The  infecting 
germs  lie  upon  the  surface  and  in  the  glands  and  in  the  interglandular  tissue  and 
even  in  the  underlying  muscular  tissue.  The  chronic  hyperemia  gives  rise  to  in- 
creased secretion  from  the  glands,  and  this  secretion  combines  with  the  leucocytes 
and  epithelial  cells  and  micro-organisms,  and  forms  a  muco-purulent  discharge 
which  as  it  passes  through  the  cervix  becomes  associated  with  the  tenacious  mucous 
of  that  locality.  The  germs  may  disappear  entirely  after  several  months  or  several 
years,  but  the  changed  tissue  then  present  may  act  as  an  irritant  and  keep  up  the 
inflammation  as  a  simple  endometritis.  In  fact,  it  is  held  by  some  that  in  ordinary 
chronic  infected  endometritis,  the  micro-organisms  play  only  a  small  part. 

The  congestion  and  the  described  condition  of  the  mucosa  usually  give  rise  to 
a  hemorrhagic  tendency.     The  hypertrophy  or  hyperplasia  may  progi-ess  to  such 


568 


DISEASES  OF  THE  UTERUS 


an  extent  that  the  mucosa  beeomes  many  times  its  usual  thickness.  When 
the  hyperplasia  is  so  marked,  it  usually  takes  place  unevenly,  so  that  the 
surface  is  rough  and  nodular,  giving  rise  to  the  name  "fungous"  endometritis. 
The  normal  endometrium  is  shown  in  Fig.  568.  Chronic  endometritis  of  the 
fungous  form  is  shown  in  Figs.  569,  570.  In  this  condition  the  hemorrhagic 
tendency  is  a  marked  feature,  hence  the  name  "hemorrhagic"  endometritis. 
In  some  cases  the  masses  project  out  from  the  surface  and  become  pedi- 
culated  and  give  rise  to  polypi.  This  condition  is  known  also  as  "poly- 
poid" endometritis.  The  gland-ducts  become  obstructed  and  retention 
cysts  are  thus  formed.  In  the  fungus  and  polypoid  form  of  endome- 
tritis, the  interstitial  tissue  in  the  endometrium  undergoes  decided  increase 
and    hence    the    condition    is    sometimes  designated    interstitial  endometritis, 


Fig.  568.  A  Normal  Uterus  divided  from  in  front,  showing  the 
Smoothness  of  the  Endometrium  and  also  its  relative  Thickness. 
(CuWen— Cancer  of  the  Uterus.) 

in  contradistinction  to  glandular  endometritis,  in  which  there  is  marked  pro- 
liferation of  the  glands  without  corresponding  increase  in  the  connective  tissue. 
After  a  long  time  the  cellular  infiltration  largely  disappears,  new  connective  tissue 
taking  its  place,  and  this  connective  tissue  contracts  as  the  infiltration-cells  between 
the  fibers  disappear.  The  glands  arc  thus  injuriously  pressed  upon  and  begin  to 
undergo  pressure-atrophy,  their  ducts  are  obstructed  and  cystic  dilatation  takes 
place.  This  process  becomes  more  and  more  marked  until  there  is  great  destruc- 
tion of  gland  tissue  and  the  condition  passes  into  sclerosis  of  the  uterus,  described 
later,  in  which  little  remains  of  the  mucosa  but  scar-tissue.  The  change  from  ordi- 
nary chronic  endometritis  to  the  condition  of  sclerosis  takes  several  years,  except 


SYMPTOMS  OF  CHRONIC  INFECTED  ENDOMETRITIS 


569 


in  those  cases  in  which  the  process  is  hastened  by  the  use  of  destructive  apphca- 
tions  within  the  uterus. 


Symptoms. 

The  patient  comes  complaining  of  a  vaginal  discharge  (leucorrhoea)  which  she 
has  had  for  several  months  or  years,  as  the  case  may  be.  This  may  be  the  only 
symptom.  Usually,  however,  there  are  marked  menstrual  disturbances — painful 
menstruation,  increased  menstrual  flow  and  frequently  irregular  menstruation. 
When  hypertrophy  of  the  endometrium  is  a  marked  feature  of  the  endometritis, 
the  hemorrhagic  tendency  is  likewise  marked.  The  menses  may  last  a  week  or 
ten  days,  and  bleeding  between  times  may  appear.  Hemorrhage  is  especially 
marked  in  the  fungous  or  polypoid  condition  of  the  endometrium.  A  polypus 
thus  formed,  may  give  rise  to  sudden  serious  uterine  hemorrhage.  Occasionally 
the  menstrual  flow  is  diminished,  but  usually  not  unless  atrophic  changes  arc  pres- 
ent. 

Backache  and  weight  in  the  pelvis  and  dragging  pains  very 
frequently  accompany  endometritis.  The  patient  tires  easily 
and  can  not  do  the  work  nor  the  walking  that  she  formerly 
could.  All  these  symptoms  are,  as  a  rule,  much  worse  than 
menstrual  period.  Sterility  is  usually  present  if  the  endo- 
metrial changes  are  marked.  Reflex  disturbances  may  also 
appear, 


Fig.  569.  Chronic  Endometritis,  polypoid  or  fungus  form.  The  area  from 
whici  the  magnified  portion  (Fig.  570)  was  taken  is  indicated  at  (1). 
(Cullen— Cancer  of  the  Uterus.) 


Fig.  570.  A  Section 
from  the  uterus  shown  in 
Fig.  569,  highly  magnified. 
(Cullen  —  Cancer  of  the 
Uterus.) 


570  DISEASES  OF  THE  UTERUS 

There  are  often  also  more  severe  symptoms  due  to  some  associated  affection, 
such  as  salpingitis  or  malposition  or  the  uterus.  By  questioning  the  patient  it 
can  usually  he  determined  whether  the  acute  infection  was  gonorrhoeal  or  ordinary 
septic  inflammation.  The  questioning  should  always  be  conducted,  of  course, 
in  such  a  way  as  not  to  arouse  the  patient's  suspicion  of  disease  in  her  husband. 
If  the  process  has  continued  long,  the  uterus  is  generally  increased  in  size,  par- 
ticularly so  when  the  infection  followed  labor  or  abortion,  with  resulting  subinvo- 
lution. In  the  examination,  search  should  of  course  be  made  for  tubal  compli- 
cations and  other  associated  diseases.  If  salpingitis  is  present,  it  shows  that  in- 
fection has  extended  to  the  endometrium  and  thence  to  the  tube. 

On  speculum  examination,  it  is  seen  that  the  discharge  comes  from  the  uterus, 
for  it  is  found  about  the  external  os  and  in  the  cervical  canal.  The  amount  of 
discharge  coming  from  the  uterus  may  be  determined,  if  desired,  by  placing  a 
tampon  against  the  cervix  and  removing  it  after  twelve  to  twenty-four  hours. 
In  chronic  endometritis  the  discharge  may  be  slight  or  free,  and  it  is  usually  mixed 
with  much  cervical  mucous.  There  is  more  discharge  than  can  be  accounted 
for  by  the  cervical  lesions  present.  If  the  uterine  sound  be  introduced,  the  interior 
of  the  uterus  is  usually  more  sensitive  than  usual,  bleeds  more  easily  and  is  slightly 
increased  in  size — but  sounding  is  rarely  advisable. 

The  diseases  w^hich  are  most  likely  to  be  confused  with  chronic  infected  endo- 
metritis are  as  follows: 

Endocervicitis.  In  endocervicitis,  the  cervix  presents  evidence  of  inflammation 
enough  to  account  for  the  discharge,  and  there  is  no  enlargement  or  tenderness 
of  the  uterus  or  evidence  of  tubal  inflammation. 

Chronic  simple  endometritis.  In  this  there  is  no  infection  of  the  uterus  and  no 
tubal  infection  of  intrauterine  origin.  Endometritis  in  a  virgin  is  almost  always 
of  this  character. 

Subinvolution  without  infection,  presents  a  large  uterus  with  discharge  and 
menstrual  disturl^ance,  but  without  any  history  of  infection. 

Tuberculosis  of  uterus.  In  this  there  are  usually  evidences  of  tubercular  disease 
of  the  tubes  and  pelvic  peritoneum.  It  resists  the  treatment  for  endometritis, 
and  tubercular  bacilli  are  found  in  the  discharge  or  scrapings,  or  in  tissues  removed 
by  curetment. 

Malignant  disease  of  the  endometrium.  In  malignant  disease,  the  apparent 
endometritis  does  not  yield  to  regular  treatment,  and  when  the  uterus  is  cleared 
out  with  a  curet  and  the  scrapings  examined  microscopically,  malignant  infil- 
tration is  found. 

Treatment. 

1.  General  measures.  The  patient  should  rest  in  bed  as  much  as  possible 
during  the  menstrual  periods  and  also  during  any  acute  exacerbation  of  the  trouble. 

Use  purgatives  and  laxatives  sufficiently  to  keep  the  bowels  well  open.  Ergotin 
and  hydrastis  have  some  affect  on  the  uterus  and  are  indicated  in  hemorrhagic 
conditions  and  in  hypertrophy.  For  the  relief  of  pain  at  the  menstrual  period 
or  at  other  times,  the  sedative  measures  mentionetl  under  Dysmenorrhoea  are 
employed.     Sitz-baths  taken  just  before  retiring  often  give  much  relief  to  those 


TREATMENT  OF  CHRONIC  INFECTED  ENDOMETRITIS  571 

patients  complaining  of  pain  in  tlio  l)ack  and  sacrum  and  pelvis  and  down  thighs, 
worse  at  the  close  of  the  day. 

Look  for  any  extra-genital  disease  requiring  attention.  Put  the  patient  in  the 
best  possible  general  health.  Correct  any  dyscrasia  present.  Poor  blood  from 
general  diathetic  disease  often  tends  to  keep  up  chronic  inflammation  in  the  uterus. 

2.  Hot  vaginal  douches.  These  should  be  given  one  to  three  times  daily, 
depending  on  the  amount  of  discharge  and  the  amount  of  pain.  Tlie  necessary 
details  are  described  in  chapter  iii  (page  311). 

3.  Intra=uterine  applications.  In  cases  in  which  the  inflammation  is  not  severe, 
intra-uterine  applications  may  be  of  benefit.  In  the  hemorrhagic  form,  the 
hemorrhage  may  be  lessened  temporarily  by  these,  as  may  also  the  muco-purulent 
discharge.  The  details  of  intra-uterine  applications  are  explained  in  chapter  iii 
(page  346).     The  following  jnedicines  may  be  used: 

Argent,  iiitrat.,  4%  to  20%. 

Protargol,  2%  to  10%. 

CarboUc  acid. 

Tinct.  Iodine. 

Carbolic  and  Tinct.  Iodine,  half  and  half. 

Copper  sulphate,  10%. 

Formol,  10%  to  40%. 

These  applications  to  the  endometrium  may  be  made  once  a  week.  After  the 
application,  place  a  tampon  soaked  in  protargol-glycerine  or  ichthyol-glycerine 
against  the  cervix.  Then  instruct  the  patient  to  lie  down  for  several  hours  when 
she  gets  home,  and  remove  the  tampon  at  the  next  douche  time. 

Uterine  pencils  or  bougies  of  protargol  or  of  alum  and  iodoform  may  be 
used  (page  349). 

When  using  strong  applications,  such  as  carbolic  acid  or  iodo-phenol,  it  is  well 
to  introduce  a  small-sized  cervix-speculum  past  the  internal  os  and  make  the 
application  through  it,  to  prevent  the  liquid  being  squeezed  out  in  the  cervix 
and  producing  a  cauterizing  effect  with  resulting  stenosis  at  the  internal  os. 

4.  Curetment.  If  a  short  course  of  treatment  by  intra-uterine  applications  does 
not  produce  decided  benefit,  it  should  be  discontinued  and  some  more  radical 
means  employed. 

Curetment  for  Chronic  Endometritis. 

In  a  large  number  of  the  cases  of  chronic  endometritis,  curetment  is  advisable 
as  the  first  step  in  the  treatment.  In  deep-seated  chronic  inflammation  of  the 
uterus  there  is  a  large  amount  of  thickened  tissue  (Figs.  569,  570)  w^hich  must  be 
removed.  In  these  severe  cases,  it  is  a  waste  of  time  to  make  applications  or 
irrigations  before  this  is  done,  as  they  do  not  penetrate  the  diseased  mucosa  sufi- 
ciently  to  do  any  good.  The  curet  removes  the  bulk  of  this  diseased  tissue.  Then, 
if  necessary  later,  applications  may  be  made  with  the  prospect  of  getting  a 
decided  effect  from  them. 

The  preparations  for    curetment    are  the  same  as  for  repair  of  the  pelvic  floor. 


572  DISEASES  OF  THE  UTERUS 

The  instruments  required  are  shown  in  Fig.  571.  If  it  is  desired  to  cleanse  the 
uterine  cavity  by  irrigation,  instead  of  swabbing,  add  an  intra-uterine  irrigating 
tube.  If  a  piece  of  the  cervix  is  to  be  excised  for  microscopic  examination,  add 
a  long  sharp-pointed  scissors,  two  strong  cervix  needles,  a  needle-holder  and 
suture  material. 

If  the  operation  is  to  be  done  at  the  patient's  home,  a  kitchen  table  is  arranged 
for  it,  as  shown  in  Fig.  572. 


Fig.  571.  Instruments  for  Curetment :  a,  Edebohl's  self-retaining  speculum  ;  b,  vaginal  dressing-forceps, 
for  cleansing  vagina  ;  c,  long  tenaculum-forceps,  for  holding  cervix  ;  d,  uterine  dressing-forceps,  for  swabbing 
within  uterus  ;  e,  uterine  sound  (the  bulbous  end  does  not  show  distinctly  in  the  photograph);  f,  small  uterine 
dilator;  g,  large  uterine  dilator  (Wathen's);  h,  sharp  uterine  curet  with  flexible  shank,  large  size;  i,  sharp 
uterine  curet,  small  size;  j,  short  scissors  for  cutting  gauze.  If  a  piece  from  the  cervix  is  to  be  excised  for 
microscopic  examination,  add  a  long  sharp-pointed  scissors  and  suture  material  and  needles  and  a  needle- 
holder. 


Steps  in  the  operation.  1 .  The  patient  is  anesthetized  and  placed  in  the  dorsal 
posture,  with  the  feet  in  the  upright  supports  and  the  hips  at  the  edge  of  the  table 
(Fig.  573).  The  external  genitals  and  adjacent  surfaces  are  thoroughly  scrubbed 
(having  been  shaved  in  the  preparation  before  anesthesia)  with  boiled  water  and 
some  liquid  preparation  of  green  soap,  using  ])ipcos  of  al)sorbent  cotton  or  a  very 
soft  brush.     Then  the  vagina  is  vigorously  cleansed  with  the  soap  solution,  using 


CURETMENT 


573 


cotton-balls  held  in  long  forceps  and  introducing;  two  fingers  into  the  vagina  to 
spread  out  the  walls  and  smooth  out  the  depressions  so  as  to  permit  thorough 
cleansing  of  the  walls  (Figs.  574,.  575).  Then  cleanse  the  vagina  and  external 
genitals  thoroughly  with  bichloride  solution  (1-2000),  using  the  absorbent  cotton. 


Fig.  572.  A  Kitchen  Table  Arranged  for  Curetment  or  other  vaginal 
operation.  The  portable  leg-holders  can  be  carried  in  the  satchel  and  are 
very  convenient. 


Then  introduce  the  self-retaining  speculum  and  attach  to  it  a  bottle  containing 
enough  water  to  furnish  the  required  weight  (Fig.  576)  and  surround  the  operative 
field  with  towels  wrung  out  of  bichloride  solution  (1-2000)  or  with  towels  dry- 
sterilized  or  with  the  sterile  ''perineal  sheet"  (Fig.  577).     The  bottle  used  for  a 


574 


DISEASES  OF  THE  UTERUS 


weight  is  not  sterile,  consequently  it  must  not  be  touched  directly  by  the  oper- 
ator. If  it  is  necessary  for  it  to  be  hung  on  the  speculum  by  him,  he  must  grasp 
it  with  a  sterile  towel.  During  the  operation  it  is  entirely  covered  by  the  sterile 
sheet. 

2.     Swab  out  the  vagina  again  with  the  antiseptic  solution  (at  the  same  time 


Fig.  573.     The  patient  in  position  at  the  end  of  the  table.     Aher  tne  patient  is  anesthetized,  the  feet  are  fast- 
ened in  the  leg-supports  and  the  hips  are  brought  over  the  end  of  the  table. 


swabbing  out  the  cervical  canal  if  it  is  sufhciently  open),  catch  the  cervix  with 
the  tenaculum-forceps  and  dilate  it  with  the  small  dilator. 

The  canal  is  now  open  so  that  the  uterine  cavity  may  be  cleansed  with  the 
antiseptic  solution,  using  cotton  hekl  in  the  utei'ine  forceps.  Then  the  large  di- 
lator is  introduced  and  the  cervi.x  is  thoroughly  dilated  (Figs.  578,  579).  Th':' 
dilatation  should  bo  cairied  out  slowly  and  carefully,  the  direction  of  the  dilata- 
tion being  several  times  changed,  to  secure  gradual  dilatation  in  all  directions 


curetment 


575 


and  prevent  rupture  of  cervix. 
The  cervix  should,  in  tliis  man- 
ner, be  dilated  sufficiently  to  ad- 
mit the  large  curet  easily. 

In  certain  cases  in  which  the 
cervix  is  abnormal,  it  may  sud- 
denly tear  at  some  point  and  the 
blade  of  the  dilator  will  pass 
through  the  wall  of  the  cervix 
into  the  peri-uterine  connective 
tissue.  To  prevent  this  accident 
it  is  well  to  keep  the  set-screw 
at  the  handle  between  the  ]:)lades, 
set  so  that  there  can  be  no  sudden 
wide  separation  of  the  dilating 
portion  of  the  blades.  A  dilata- 
tion of  f  in.  to  I4  in.  should 
be  secured. 

3.  Cleanse  the  cavity  again 
and  introduce  the  large  curet 
(Fig.  5S0)  and  clear  out  the  soft- 
ened endometrium.  The  curet 
should  1)6   held  tightly  between 


Fig.  574.  Scrubbing  the  Vagina.  The  two  fingers 
are  introduced  and  spread  apart,  as  shown  in  Fig.  575, 
so  as  to  smooth  out  all  folds. 


Fig.  575.  Showing  how  the  fingers  are  separated 
within  the  vagina.  Showing  also  the  long  strong  for- 
ceps holding  cotton  with  which  the  vaginal  walls  are 
throughly  scrubbed. 


the  thumb  and  fingers,  in  the 
same  manner  as  a  pen  (Fig.  581). 
A  mark  on  the  handle  indicates 
in  which  chrection  the  cutting 
edge  lies.  The  interior  of  the 
uterus  should  be  gone  over  syste- 
matically, so  that  no  part  of  the 
surface  is  missed.  The  pressure 
must  be  applied  carefully.  It 
must  be  firm  enough  to  remove 
the  softened  diseased  tissue,  but 
not  firm  enough  to  remove  any 
of  the  firm  tissue  beneath  it. 
The  fact  that  comparatively 
healthy  firm  tissue  has  been 
reached  is  indicated  by  the  grat- 
ing sensation  imparted  to  the 
curet.  As  a  rule  this  is  easily 
recognized,  and  after  some 
practice  the  uterus  may  l^e  cleared 
out  rapidly  and  safely.  In  ex- 
ceptional   cases,     however,    the 


576 


DISEASES  OF  THE  UTERUS 


wall  of  the  uterus  is  diseased  to  a  considerable  extent  and  softened,  and  care 
is  necessary  to  avoid  penetration  of  the  wall. 

If  the  apparent  inflammation  has  been  of  long  standing,  the  scrapings  should 
be  saved  and  submitted  to  microscopic  examination,  that  malignant  disease  or 
tuberculosis  may  be  discovered,  if  present. 

After  the  surface  has  been  systematically  gone  over  with  the  sharp  curet,  the 


Fig.  576.  Self-retaining  Speculum  introduced,  and 
weight  (bottle  with  water  in)  attached.  The 
amount  of  weight  may  be  varied  as  necessary  for  dif- 
ferent patients  by  putting  more  or  less  water  in  the 
bottle. 


Fig.  577.     Sterile  "perineal   sheet"  arranged  about  the 
field  of  operation. 


debris  is  removed  Ijy  swabbing  with  cotton  in  a  forceps  or  by  irrigation  if   pre- 
ferred. 

4.  When  the  cavity  is  free  of  fragments,  it  is  packed  with  antiseptic  gauze,  to 
maintain  the  dilatation  of  the  cervix  for  forty-eight  hours.  If  there  is  much 
bleeding  it  may  be  diminished  ))y  one  or  two  applications  of  carbolic  acid  (95%) 
rtiade  to  the  endometrium  before  the  packing.  If  the  carbolic  application  is 
made,  care  must  be  exercised  to  prevent  the  vagina  being  burned  by  it. 


CURETMENT 


ra 


5.  After  the  uterine  cavity  has  been  packed,  cleanse  the  vagina,  introduce 
two  fingers  in  the  vagina,  remove  the  specukim  and  bring  the  fundus  uteri  well 
forward  by  bimanual  manipulation   (Fig.   582).     In  the  curetment,  the  uterus 

is   drawn  d  o  w  n  w  a  r  d  

somewhat  and    the  fun-  '  ^^r«x 

dus  sometimes  goes  back- 
ward. Unless  the  uterus 
is  brought  forward  into 
normal  position  at  the 
close  of  the  operation, 
it  is  likely  to  remain  in 
retro-displacement  and 
cause  trouble. 

If  it  is  desired  to  have 
the  vaginal  and  intra- 
uterine packing  all  in  one 
piece,  so  that  it  can  be 
more  easily  removed 
later,  the  vaginal  portion 
may  be  held  in  the  palm 
of  the  hand  (Fig.  583) 
during  the  replacement 
of  the  uterus. 

At  the  same  time  that 
the  fundus  uteri  is  being 


Fig.  578.     Introducing  the  Large  Dilator. 


Fig.  579.     The    Large  Dilator  in  Place.      (Gilliam— Prac<icai    Gynecoloyy.) 


brought  for- 
ward (or  be- 
fore beginning 
the  curet- 
ment, if 
thought  pre- 
ferable) a  pel- 
vic examina- 
tion under 
anesthesia 
may  be  made. 
In  many  of 
these  cases  of 
chronic  endo- 
metritis, there 
are  tubal  or 
ovarion  com- 
plications, the 
nature  and 
extent    of 


>7S 


DISEASES  OF  THE  UTERUS 


Fig.  580.  Introducing  the  Curet.  This  shows  the 
form  of  the  curet  and  also  tlie  manner  of  steadying  the 
cervix  with  a  tenaculum-forceps. 


Fig.  581.  Metliod  of  Holding  tlie  Curet.  It  should  be  held  like  a  pen,  so  that  every  gradation  of  force  may 
be  appreciated  and  regulated.  The  cutting  edge  of  the  curet  is  to  be  turned  in  every  direction  and  the  shank 
bent  .tvifficiently  to  systematically  curet  all  pait.s  of  the  cavity 


CU  RET. ME. N'T 


679 


Fig.  582.  lletuniing  tlie  Uterus  tu  it.'^  Xoriual  Pi^i.-^ition,  after  cuietment, 
and  making  the  Bimanual  Examination  under  An^thesia.  The  Ex- 
amination under  Anesthesia  may  be  made  immediately  before  the  curet- 
ment  if  preferred. 


which  are  best  made  out  by 
examination  under  anesthesia. 
Again,  a  frequent  compUcation 
of  chronic  endometritis  is  adher- 
ent retroversion,  and  it  is  im- 
portant to  determine  exactly  the 
environment  of  the  u  t  e  r  u  s  — 
whether  it  can  be  brought  for- 
ward without  danger,  how  firm 
and  extensive  the  adhesions  are 
and  whether  there  is  any  collec- 
tion of  pus  in  the  mass  of  adhe- 
sions or  in  the  tubes. 

6.  When  the  uterus  is  in 
normal  position,  remove  the 
tenaculum-forceps  from  the  cer- 
vix, spread  the  vagina  open  with 
the  examining  fingers  and  pack 
the  vagina  lightly  with  gauze 
(Fig.    583).      When    this    vag- 


Fig.  583.     Putting  in  the  Vaginal  Packing. 


580 


DISEASES  OF  THE  UTERUS 


Fig.  584.     The   Vaginal  Packing   in    Place,  and  the  Fig.  585.     The  Sterile  Sheet  Removed,  and  the  parts 

parts  cleansed.  ready  for  the  dressing. 


Fig.  586.      The  Vulvar  Dressing.      The  Gauze  Applied. 


Fig.  587.     The    Vulvar   Dressing.      The    Absorbent 
Cotton  applied  over  the  gauze. 


CURETMENT 


581 


inal  packing  is  finished 
(Fig.  584),  remove  the 
sterile  sheet  (Fig.  585) 
and  put  on  the  dressing 
— fir.st,  a  piece  of  gauze 
(Fig.  586),  then  a  large 
piece  of  absorbent  cotton 
(Fig.  587)  and  then  the 
T-bandage  (Fig.  588). 

After  the  curetment,  in 
chronic  endometritis 
without  active  germs,  the 
interior  of  the  uterus  is 
again  covered  with  epi- 
thelium in  two  weeks 
(Fig.  589),  and  at  the  end 
of  two  or  three  months 
the  whole  endometrium 
is  restored  (Figs.  590  and 
591).  This  new  endome- 
trial covering  is  supposed 
to  come  from  the  mul- 
tipUcation  of  the  epi- 
thelial cells  lining  the 
deeper    portions    of    the 


a— 


Fig.  588.  The  Vulvar  Dressing.  The  T-bandage  applied. 
Notice  in  Figs.  587  and  588  that  the  dressing  covers  the  entire 
vicinitj-  of  the  operative  field,  including  the  pubes. 


C ; 


^^rS^^ 


p- 


(B.  <KI>  -^■ 


Fig.  589.     Perpendicular  Section  of  the  Uterine  Mucous  Membrane,  Thirteen  Days  After  Curetment : 
a,  b,  epithelium,  newly-formed.     (Baldy — American  Text -book  of  Gynecology.) 


Fig.  590.  Vertical  Section  of  the  Uterine  Mucous  Membrane,  Thirty-one  Days  After  Curetment: 
a,  a,  a,  cylindrical  epithelium;  b.  d,  proliferating  cells  in  the  deeper  part  of  the  epithelium;  c,  newly- 
formed  stroma.      (Baldy— American  Textbook  of  Gynecology.) 


5S2 


DISEASES  OF  THE  UTERUS 


Fig.  591.  Vertical  Section  of  Uterine  Mucous  Membrane,  Three  Months  After  Curetment :  a  epithe- 
lium; b.  newly-formed  glands;  c,  stroma  tissue;  d,  muscular  tissue  of  the  uterine  wall.  (Baldy — 
American  Text-hook  of  Gynecology .) 


^^^ 
^^"M 


i 


^ 


P"ig.  592.  Vertical  Section  of  the  Uterine  Mucous  Membrane.  Fifly- 
three  Days  After  the  Application  of  a  Caustic:  a,  epithelium;  b,  con- 
nective tissue;  c.  c.  sections  of  glands  wliich  have  undergone  cystic 
degeneration;  d,  tubular  gland.s  enormously  dilated;  in,  muscular 
ti.ssue  of  the  uterine  wall.    (Baldy— .•Imerionn  7'e.rt-book  of  Gynecology.) 


glands  Avhich  are  not 
removed  in  the  curet- 
ment. 

This  rapid  gi'owth 
of  a  new  (and  presum- 
ably more  healthy)  en- 
dometrium after  cu- 
retment,  contrasts 
markedly  with  the  re- 
sults following  cauter- 
ization of  the  endome- 
trium with  strong  cau- 
terants,  such  as  nitric 
acid  or  chloride  of 
zinc,  which  were  form- 
erly much  employed. 
Fig.  592  shows  the  re- 
sult of  such  destructive 
caustic  action,  and 
should  serve  as  a  suffi- 
cient warning  against 
the  use  of  destructive 
cauterants  within  the 
uterus  before  the  meno- 
pause. 

After=care.  The  an- 
tiseptic care  of  a  pa- 
tient after  curetmeni 
is  practically  the  same 
as  after  repair  of  cervix. 


CHRONIC  SIMPLE  ENDOMETRITIS  583 

The  vaginal  and  uterine  packing  is  removed  in  about  forty-eight  hours,  and  an 
antiseptic  vaginal  douche  (e.  g.,  1-5000  bichloride)  is  given  once  daily.  The 
vulvar  dressing  is  continued  for  ten  days.  The  patient  may  ordinarily  get  up  in 
three  or  four  days  after  curetnient,  except  when  there  is  some  associated  disease 
that  would  be  benefited  by  longer  rest  in  bed — for  example,  in  chronic  salpingitis 
associated  with  chronic  endometritis,  the  patient  may  be  kept  in  bed  ten  days  to 
two  weeks  with  decided  benefit.  Some  hold  that  inflammation  in  the  tubes  or 
other  tissues  about  the  uterus  is  a  contra-indication  to  curetment,  but  I  hold  just 
the  opposite,  i.  e.,  that  chronic  pelvic  inflammation  associated  with  chronic  endo- 
metritis is  in  most  cases  benefited  by  the  curetment. 

Curetment  is  only  one  step  in  the  treatment  of  chronic  endometritis.  The  other 
measures,  previously  mentioned,  should  be  carried  out  as  before,  until  the  symp- 
toms subside.  Additional  intra-uterine  applications  of  astringents,  the  same  as 
used  before  curetment, .  may  be  necessary  in  exceptional  cases.  More  benefit 
may  be  expected  from  these  after  the  removal  of  the  bulk  of  the  diseased  tissue 
b}'  curetment  than  before.  It  is  well,  however,  not  to  disturb  the  endometrium 
for  at  least  one  month  after  the  curetment. 

Associated  pathological  conditions,  such  as  malposition  of  uterus,  laceration  of 
cervix,  laceration  of  pelvic  floor  and  pelvic  inflammation,  must  also  be  corrected, 
as  far  as  possible,  for  if  allowed  to  continue  the  uterine  congestion  resulting  there- 
from will  tend  to  prolong  the  endometritis  and  will  result  in  the  reformation  of 
a  thickened  bleeding  endometrium. 

CHRONIC  SIMPLE  ENDOMETRITIS. 

Simple  endometritis  is  endometritis  without  infection.  It  is  a  nutritive  change 
and  is  nearly  always  chronic.  It  is  known  also  as  hyperplasia  of  the  endometrium. 
In  its  various  forms  it  is  sometimes  designated  as  catarrhal  endometritis,  hyper- 
trophic endometritis,  fungous  endometritis,  polypoid  endometritis,  hemorrhagic 
endometritis,  atrophic  endometritis,  chronic  endometritis,  pseudo-metritis.  Some 
of  these  terms  are  used  to  express  particular  forms  of  chronic  simple  endometritis 
and  some  are  used  to  cover  all  forms  of  chronic  endometritis,  both  simple  and 
infected.  It  is  a  decided  advantage  to  designate  a  disease  or  condition  b}^  some 
name  which  mil,  as  far  as  practicable,  express  the  distinctive  characteristics  of 
that  disease.  An  investigation  will,  I  think,  demonstrate  to  the  reader  that  the 
names  I  have  selected  out  of  the  mass  of  names  applied  to  the  inflammatory  and 
nutritive  disease  of  the  uterus,  express  clear-cut  clinical  entities — designated  by 
their  distinguishing  characteristics  and  covering  the  field  under  consideration 
without  troublesome  over-lapping. 

Etiology. 

The  cause  of  simple  endometritis  is  a  disturbance  of  the  nutrition  of  the  endo- 
metrium without  the  intervention  of  bacteria.  This  nutritive  disturbance  is  due 
to  a  deficiency  in  the  quantity  or  quality  of  the  blood  supplied  to  the  endometrium 
or  to  special  cell-conditions.  The  particular  conditions  that  tend  to  affect  the 
endometrium  in  one  or  more  of  the  three  ways  mentioned  are  as  follows: 

1,     General  diseases  or  extra-pelvic  local  diseases  that  produce  marked  anemia, 


584  DISEASES  OF  THE  UTERUS 

for   example,   chlorosis,   phthisis,   nephritis,  leukemia,  gastro-intestinal  affections 
and  all  wasting  diseases. 

2.  General  diseases  or  extra-pelvic  local  diseases  that  cause  metabolic  by-prod- 
ucts and  other  abnormal  substances  that  circulate  in  the  blood,  for  example, 
hthiasis,  diabetes  and  all  chronic  septic  processes. 

3.  Extra-pelvic  diseases  or  conditions  causing  chronic  pelvic  congestion,  for 
example,  heart  disease  with  failing  competency,  occupations  that  necessitate  long 
standing  or  excessive  walking  or  much  lifting. 

4.  Pelvic  diseases  outside  the  uterus  causing  chronic  pelvic  congestion,  for 
example,  chronic  pelvic  inflammation,  pelvic  tumors  and  chronic  disease  of  the 
rectum  or  bladder. 

5.  Malpositions  of  the  uterus  that  interfere  with  the  circulation  of  blood  in 
the  endometrium — anteflexion,  retroflexion,  retroversion  and  prolapse. 

6.  Tumors  of  the  uterus  that  interfere  with  the  blood-circulation  of  the  endo- 
metrium— fibromyomata,  carcinomata  and  sarcomata. 

7.  Foreign  bodies  in  the  uterine  cavity,  that  keep  up  chronic  congestion  and 
irritation  of  the  endometrium,  for  example,  placental  remnants  left  after  an  abor- 
tion, or  uterine  secretions  retained  by  stenosis. 

8.  Acute  simple  endometritis,  with  the  persistence  of  some  source  of  intra- 
uterine irritation. 

9.  When  the  uterine  wall  is  physiologically  hypertrophied  and  fails  to  return 
to  its  normal  condition — subinvolution. 

10.  Retrograde  cell-changes  as  seen  during  and  following  the  menopause,  or 
abnormal  cell-changes  as  in  a  poorly-developed  uterus.  Cases  of  uterine  inflam- 
mation after  the  climacteric  originate  in  this  may,  and  later,  on  account  of  the 
discharge,  infection  may  take  place  and  acute  infected  endometritis  appear. 

Pathology. 

There  is  chronic  congestion  of  the  endometrium  and  of  the  adjacent  muscular 
tissue,  engorgment,  serous  and  cellular  infiltration  into  the  tissues,  and  hyper- 
plasia of  the  tissue  elements  in  varying  proportion.  This  is  the  usual  change. 
In  some  cases,  however,  there  is  atrophy  and  shrinking  of  the  endometrium, 
instead  of  increase  in  thickness.  Either  form,  after  continuing  many  years,  tends 
to  cin-hosis  of  the  uterus,  though  not  so  markedly  as  infected  endometritis.  As 
indicated  under  etiology,  simple  endometritis  is  nearly  always  symptomatic  of 
some  other  affection.  It  is  associated  with  and  dependent  upon  some  other  dis- 
ease, and  yet  in  the  course  of  time  that  causative  disease,  for  example  retroflexion, 
may  be  so  far  surpassed  by  the  symptoms  of  endometritis  as  to  be  of  secondary 
importance. 

In  the  hypertrophic  form,  the  glands  increase  in  number  and  length  and  there 
may  be  hyperplasia  of  the  stroma  cells.  The  endometrium  becomes  much  thick- 
ened and  in  spots  the  surface  is  imeven  and  nodular  (fungous  endometritis). 
Small  areas  of  this  cushion  of  hypertrophied  tissue  project  from  the  general  surface 
into  the  cavity.  One  of  these  projections  may  increase  until  it  becomes  peduncu- 
lated, thus  forming  a  polypus.  There  may  V)e  many  of  these  polypi,  forming 
polypoid  endometritis  (Fig.  569,  570).     This  presents  the  same  hemorrhagic  ten- 


CHRONIC  SIMPLE  ENDOMETRITIS  585 

dency  as  the  infected  hypertrophic  endometritis.  There  is  increased  secretion 
from  the  glands,  causing  discharge.  The  gland-ducts  become  obstructed,  causing 
cysts.  When  the  endometritis  follows  abortion  or  labor,  islands  of  decidual 
tissue  may  persist  for  a  long  time  and  act  as  a  source  of  irritation. 

In  the  atrophic  form,  the  change  presented  is  that  of  atrophy  of  the  essential 
tissue-elements,  leaving  the  connective  tissue  to  largely  occupy  the  field.  The 
uuml)er  of  glands  is  diminished  by  pressure  atrophy,  the  ducts  of  some  of  them 
becoming  obstructed  to  such  an  extent  that  cysts  form.  The  cytogenic  tissue 
also  is  diminished,  and  the  endometrium  becomes  unable  to  perform  its  function 
of  menstruation  or  of  nourishment  of  the  fertilized  ovum.  Of  course,  in  either 
form,  infection  may  take  place,  and  then  the  symptoms  of  infected  endometritis 
are  added  to  those  of  simple  endometritis. 

Symptoms  and  Diagnosis. 

The  symptoms  of  chronic  simple  endometritis  are  about  the  same  as  of  chronic 
infected  endometritis,  namely,  vaginal  discharge,  menstrual  disturbances,  hemor- 
rhagic tendency,  backache,  dragging  weight  in  pelvis,  tired  feeling,  sterility,  reflex 
disturbances,  enlargement  of  uterus  and  increased  sensitiveness.  The  number 
and  extent  of  the  symptoms  will  depend,  of  course,  upon  the  extent  of  the  patho- 
logical process  and  the  reaction  of  the  patient's  nervous  system.  Chronic  simple 
endometritis  differs  from  chronic  infected  endometritis  in  the  following  particulars: 

a.  There  is  no  history  of  infection,  i.  e.,  of  acute  endometritis,  either  septic  or 
gonorrhoeal.  This  simple  endometritis  is  the  form  of  endometritis  found  in  girls 
and  unmarried  women  with  menstrual  disturbances  and  in  married  women  who 
have  never  had  any  infection.  It  is  freqeuntly  found  in  the  uninfected  uterus 
which  is  the  seat  of  subinvolution  or  fibroids  or  malignant  disease  or  post  climac- 
teric inflammation. 

b.  The  discharge  is  usually  not  so  profuse  nor  so  irritating  and,  when  taken  from 
the  uterus,  it  contains  no  pathogenic  bacteria. 

c.  There  is  no  evidence  about  the  urethra  or  vulvo-vaginal  glands  of  previous 
infection. 

d.  Tubal  complications  are  very  rare. 

e.  There  is  nearly  always  some  associated  disease,  of  which  the  simple  endo- 
metritis is  symptomatic  and  which  must  be  cured  before  the  endometritis  vidll 
subside. 

Treatment. 

The  treatment  of  chronic  simple  endometritis  is  about  the  same  as  of  chronic 
infected  endometritis.     The  following  points  should  be  kept  in  mind: 

1.  The  general  condition,  especially  the  quality  and  quantity  of  the  blood 
supplied  to  the  endometrium,  is  of  more  importance  and  consequently  the  general 
treatment  must  be  carefully  considered. 

2.  The  endometritis  is  dependent,  usually,  upon  some  other  disease  which 
must  be  corrected  before  the  endometritis  can  be  cured. 

3.  When  it  is  found  in  virgins,  or  suspected  from  the  symptoms,  attempt  ameli- 
oration by  general  treatment   (blood,  bowels,  kidneys,  muscular  system,  skin, 


580  DISEASES  OF  THE  UTERUS 

gastro-intestinal  tract)  and  avoid  local  examination  or  treatment,  except  in  those 
cases  where  the  urgency  of  the  symptoms  or  the  persistence  of  the  affection  makes 
local  treatment  necessary.  General  measures  in  the  virgin  are  to  be  tried  first. 
If  they  fail,  then  local  measures  such  as  vaginal  douches  may  be  added.  If  they 
fail,  then  the  question  of  intra-uterine  treatment  is  to  be  considered. 

4.  In  virgins,  intra-uterine  applications  are  not,  as  a  rule,  advisable.  The 
vaginal  orifice  is  small,  the  cervical  canal  is  small  and  the  applications  are  painful 
and  unsatisfactory.  Beside  that,  the  nervous  shock  incident  to  the  necessary 
exposure  is  much  greater  in  the  virgin.  For  these  reasons  and  the  additional  one 
that  in  those  cases  in  which  intra-uterine  treatment  is  required  applications  alone 
usually  fail,  my  rule  is  to  begin  the  local  treatment  in  virgins  by  giving  an  anes- 
thetic and  clearing  out  the  diseased  endometrium  with  the  curet,  that  a  new 
and  healthy  endometrium  may  develop  under  better  conditions.  Frequently  all 
local  applications  will  thus  be  avoided.  If  further  intra-uterine  treatment  is 
required,  applications  may  be  made  afterward  more  staisfactorily  and  with  less 
pain  to  the  patient. 

If  applications  are  needed,  the  ones  mentioned  on  page  351  may  be  used.  In 
the  hemorrhagic  form,  copper  sulphate  solution  (10%),  tincture  of  iodine  and  iodo- 
phenol  are  applicable.  In  the  atrophic  form  (the  most  stubborn  and  painful 
variety),  ichthyol  10%  to  50%  in  glycerine  has  produced  beneficial  results.  Pure 
ichthyol  is  sometimes  used.  It  is  well  in  the  atrophic  form  to  combine  the  appli- 
cations with  drainage  by  antiseptic  gauze. 

In  patients  who  object  to  curetment  or  in  the  cases  in  which  the  endometritis 
is  so  mild  or  of  such  short  duration  that  it  will  probably  yield  to  applications, 
the  following  course  of  treatment  may  be  employed:  A  few  days  after  menstru- 
ation, under  proper  antiseptic  precautions,  introduce  a  narrow  strip  of  iodoform 
gauze  into  the  uterus.  If  necessary,  dilate  the  cervix  slightly.  Then  pack  the 
upper  part  of  the  vagina  lightly  with  gauze.  At  the  end  of  two  days  remove  the 
gauze  and  cleanse  the  parts  carefully.  Then  make  an  intra-uterine  application 
and  introduce  another  narrow  strip  of  gauze  into  the  uterus  and  another  light 
gauze  packing  into  the  upper  vagina.  At  the  end  of  two  days  the  same  process 
is  repeated.  This  may  be  kept  up  until  two  or  three  days  before  the  next  menstrual 
flow  is  expected. 

In  cases  where  the  uterine  discharge  is  free,  it  is  desirable  to  have  the  gauze 
all  in  one  strip  with  the  end  near  the  vulva,  and  direct  the  patient  to  remove  the 
gauze  the  next  day  after  it  is  introduced  and  then  take  a  hot  antiseptic  douche 
every  6  to  12  hours  until  the  next  intra-uterine  application,  which  is  made  every 
two  or  three  days.  During  the  course  of  treatment  the  patient  should  lie  down  a 
large  portion  of  the  time  and  should  do  but  little  walking  and  no  work.  If  decided 
improvement  follows  this  course  of  treatment  it  may,  if  necessary,  be  carried  out 
in  one  or  two  succeeding  intermenstrual  periods.  If  there  is  no  decided  improve- 
ment from  the  first  course  of  two  or  three  weeks,  it  is  a  waste  of  time  to  try  it 
longer.  Curetment  is  then  necessary.  During  curetment,  if  the  uterus  is  in 
backward  displacement  it  should  bo  brought  forward  into  normal  position,  if 
practicable.  In  anteflexion,  which  in  virgins  is  very  frequently  associated  with 
simple  endometritis,  the  dilatation  incident    to  curetment    and  the    subsequent 


SUBINVOLUTION  OF  THE  UTERUS  5g7 

intra-uterine  gauze-packing,  tends  to  some  extent  to  overcome  the  flexion  and 
the  resulting  stenosis. 

The  removal  of  the  causative  disease  in  every  case  is  very  important,  for  unless 
it  is  removed  there  is  strong  probability  of  recurrence. 

5.  The  prognosis  is  better,  provided  the  causative  disease  can  l^e  removed, 
for  there  are  no  bacteria  to  keep  uo  chronic  irritation  and  congestion  in  the  uterus. 

SUBINVOLUTION  OF  UTERUS. 

Subinvolution  is  the  term  applied  to  that  condition  of  the  uterus  found  in  cases 
in  which,  after  labor  or  abortion,  it  fails  to  return  to  its  normal  size.  It  remains 
large  and  heavy,  and  its  walls  have  not  the  usual  tone  and  firmness. 

Etiology. 

Subinvolution  is  due  to  some  interference  with  the  retrograde  changes  that 
normally  follow  labor.  These  retrogi-ade  changes  that  normally  take  place,  con- 
sist of  atrophy  of  the  muscular  and  connective  tissue.  Fatty  degeneration,  which 
was  formerly  supposed  to  occupy  such  a  prominent  place  in  the  process,  has  been 
found  to  be  a  subordinate  feature.  The  retrograde  changes  may  be  interfered 
with  iDy  anything  that  prevents  proper  contraction  and  retraction  of  the  uterus 
or  that  causes  chronic  congestion. 

A  uterus  which  becomes  infected  after  labor  does  not  return  to  its  normal  size 
unless  the  infection  is  overcome. 

Retained  membranes  or  placental  remnants  also  interfere  with  the  process  of 
involution,  even  without  infection. 

General  diseases  producing  an  impoverished  condition  of  the  blood  may,  follow- 
ing labor,  so  interfere  with  the  nutrition  of  the  uterus  as  to  cause  subinvolution. 

Retrodisplacement  of  the  uterus  after  labor  or  abortion,  is  another  cause  of 
subinvolution. 

Pathology. 

The  uterus  is  much  thickened,  both  the  muscular  wall  and  the  mucous  lining 
being  involved.  Usually  both  the  body  and  the  cervix  are  affected,  though  either 
may  be  affected  alone.  The  muscular  fibers  remain  enlarged  and  show  some  fatty 
degeneration.  There  is  a  glandular  hypertrophy  in  the  mucous  membrane  and 
the  lymph-spaces  remain  enlarged.  The  enlarged  uterus  often  tends  to  sink  low 
in  the  pelvis  and  to  fall  into  retrodisplacement.  When  subinvolution  has  been 
present  for  a  long  time,  more  or  less  connective-tissue  hyperplasia  takes  place  and 
the  change  becomes,  to  some  extent,  a  permanent  one.  There  is  usually  emplanted 
on  the  condition,  a  simple  endometritis  of  the  hypertrophic  variety. 

Symptoms  and  Diagnosis. 

The  symptoms  of  subinvolution  are  simply  a  sense  of  weight  and  pressure  and 
weakness  in  the  pelvis,  with  menstrual  disturbances  (usually  increased  flow). 
As  a  rule  the  most  prominent  symptoms  are  those  due  to  complications,  such  as 
simple  endometritis,  infected  endometritis  or  retrodisplacement. 


588  DISEASES  OF  THE  UTERUS 

In  practically  all  cases  of  infection  following  labor  or  abortion,  there  is  subin- 
volution, but  as  the  endometritis  is  the  more  important  lesion,  these  cases  are 
classed  as  endometritis  The  term  subinvolution  is  left  for  those  cases  in  which 
the  enlargement  and  softening  of  the  uterus  is  the  principal  lesion. 

The  enlarged  uterus  is  found  low  in  the  pelvis  and  not  particularly  tender, 
unless  there  is  a  complicating  endometritis.  The  uterus  may  be  retro  verted  and 
there  is  often  laceration  of  the  pelvic  floor.  The  history  connects  the  trouble 
with  a  previous  labor  or  miscarriage, 

Treatment. 

The  principal  disturbances  accompanying  subinvolution  come  from  the  associ- 
ated diseases,  consequently  the  treatment  is  directed  largely  to  the  associated 
conditions.  The  following  measures  tend  to  tone  up  and  improve  the  condition 
of  the  uterine  wall  and  tend  also  to  benefit  the  accompanying  endometritis. 

1.  Give  general  tonics  as  indicated  by  the  patient's  general  condition,  and 
uterine  astringents  (ergotin,  hydrastis,  stypticin)  to  tone  up  the  uterine  wall. 

2.  Give  laxatives  as  indicated  by  the  condition  of  the  intestinal  tract. 

3.  Give  hot  vaginal  douches  (antiseptic  and  astringent),  for  example,  the 
bichloride  douche  or  the  alum  and  zinc  sulphate  douche  (see  Formulae). 

4.  Make  intra-uterine  applications,  if  indicated  by  the  existing  endometritis. 
Also,  employs  scarification  or  ichthyol-glycerine  tampons  or  vaginal  suppositories 
when  indicated. 

5.  Electricity  is  sometimes  of  benefit — vagino-abdominal  and  utero-abdominal 
applications  of  either  the  galvanic  current  or  faradic  current. 

6.  Curetment  is  the  most  effective  measure  for  checking  the  endometritis  and 
reducing  the  size  of  the  uterus.  Curetment  should  be  followed  by  the  other  reme- 
dial measures,  such  as  hot  douches,  laxative,  uterine  astringents  internally  and, 
if  necessary,  intra-uterine  applications. 

7.  Repair  of  cervix  and  restoration  of  pelvic  floor  may  be  indicated.  Where 
the  cervix  has  been  severely  torn  or  there  is  severe  laceration  of  the  pelvic  floor, 
these  lesions  must  of  course  be  repaired. 

8.  Excision  of  cervix.  If  the  cervix  is  much  elongated,  the  regular  wedge- 
shaped  amputation  may  be  carried  out  (Figs.  564,  566).  If  the  cervix  is  not  large 
enough  to  necessitate  that  and  yet  is  enlarged  and  heavy,  partial  excision  (Fig. 
561)  may  be  carried  out. 

Prophylaxis  of  Subinvolution. 

Subinvolution  is  one  of  those  diseases  which  may  in  a  measure  be  anticipated 
and  often  prevented.-  The  measures  to  be  employed  in  the  puerperium  to  avoitl 
subinvolution  are  as  follows: 

1 .  Prevent  infection  following  labor  or  abortion  by  careful  attention  to  asepsis. 

2.  See  that  the  uterus  is  emptied  of  placental  remnants  and  membranes. 

3.  Repair  all  lacerations  of  the  pelvic  floor. 

4.  Keep  the  uterus  well  contracted.  If  it  shows  a  tendency  to  remain  relaxed 
during  the  puerperum,  give  strychnine  or  ergotin  or  both.      Hydrastis  tends  to 


SCLEROSIS  OF  THE  UTERUS  5g9 

tone  up  the  uterus  and  keep  it  contracted.  Also  keep  the  bowels  open  well,  to 
relieve  pelvic  congestion,  and  nuiintaiu  the  patient  in  good  general  condition 
by  attention  to  the  general  health. 

5.  Pre^•ent  retroversion  by  keeping  the  patient  on  the  side  after  the  first 
day  or  two,  and  not  much  on  the  back.  Before  discharging  the  patient,  make  an 
examination  and  determine  certainly  that  there  is  no  displacement. 

6.  If  there  is  a  generally  relaxed  condition  of  the  tissues  (uterus,  vaginal  walls, 
etc.),  give  a  hot  vaginal  douche  (bichloride  1-5000)  twice  daily  after  the  first  week 
or  ten  days.  If  the  tissues  still  remain  relaxed,  then  change  to  the  astringent 
douche  of  alum  and  zinc  sulphate  (see  Formulae). 

HYPERINVOLUTION  OF  UTERUS. 

Hyperinvolution  is  a  very  rare  condition  in  which  the  process  of  involution 
following  labor  does  not  stop  at  the  normal  limit,  but  continues  until  the  uterus 
is  much  reduced  in  size.  The  uterus  sometimes  becomes  so  small  as  to  measure 
only  an  inch  in  depth.  The  cause  of  this  trouble  is  not  known.  The  principal 
symptom  is  painful  and  scanty  menstruation.  The  treatment  is  not  satisfac- 
tory. The  same  treatment  is  employed  as  for  the  dysmenoiThoea  and  scanty 
menstruation  of  simple  atrophic  endometritis. 

In  the  early  part  of  this  year  I  had  a  most  interesting  case  of  hyperinvolution 
of  the  uterus  and  adnexa.  The  patient  was  thirty  years  of  age.  Three  years 
previously  she  had  had  a  severe  infection  following  the  birth  of  her  child,  and  there 
had  been  no  menstruation  since.  Pelvic  examination  showed  the  uterus  to  be 
very  small.  On  account  of  other  trouble  it  was  necessary  to  open  the  abdomen, 
and  I  had  the  opportunity  of  inspecting  the  internal  genital  organs.  Every- 
thing was  atrophic — the  uterus,  ovaries,  tubes  and  round  ligaments.  The  uterus 
was  about  half  the  normal  size. 

SCLEROSIS  OF  THE  UTERUS. 

Sclerosis  of  the  uterus  is  connective-tissue  hyperplasia  of  the  deeper  portions  of 
the  uterine  wall,  resulting  from  irritation  and  disturbance  of  nutrition  as  mani- 
fested in  the  various  forms  of  endometritis.  It  is  the  final  stage  to  which  all  forms 
of  uterine  infiammation  tend  and  which  they  finally  reach  unless  checked.  It 
is  eventually  the  substitution  of  scar-tissue  (new  connective  tissue)  for  the  par- 
enchymatous tissue-elements  (epithelial  cells  and  muscular  fibers).  It  affects 
the  entire  thickness  of  the  wall,  producing  a  striking  effect  both  in  the  mucous 
membrane  and  in  the  muscular  tissue.  It  is  known  also  as  chronic  interstitial 
metritis,  areolar  hyperplasia,  cirrhosis  of  uterus  and  "irritable  uterus."  When 
located  principally  in  the  cervix,  the  seat  of  laceration  and  chronic  inflammation, 
it  is  known  as  inflammatory  hypertrophy. 

Etiology. 

It  is  due  to  persistent  chronic  inflammation  or  nutritive  disturbance  within  the 
uterus. 


590  DISEASES  OF  THE  UTERUS 

It  is  favored  by  chronic  inflammation  around  the  uterus  or  by  pelvic  tumors  that 
cause  persistent  uterine  congestion.  It  is  predisposed  to  by  diseases  that  depress 
the  general  health  and  nutrition,  especially  by  the  blood  conditions  associated 
with  cirrhosis  of  the  kidney  and  arterio-sclerosis.  It  is  usually  due  to  one  of  the 
following  chronic  affections  : 

Laceration  of  cervix,  with  resulting  chronic  inflammation. 

Ulcer  of  cervix,  with  deep  inflammation. 

Chronic  endocervicitis,  with  cystic  degeneration. 

Chronic  infected  endometritis. 

Chronic  simple  endometritis. 

Subinvolution. 

It  may  follow  destructive  cauterization  of  the  endometrium,  for  example,  with 
zinc  chloride  or  with  steam. 

Pathology. 

The  essential  changes  are  hyperplasia  of  the  connective  tissue  and  loss  of  the  par- 
enclwmatous  elements  (epithelial  cells  and  muscle  fibers).  Following  the  inflam- 
matorj^  affections,  the  connective  tissue  hyperplasia  is  more  active,  crowding  the 
special  cells  and  causilig  them  to  atrophy  and  finally  disappear.  Following  the 
purely  nutritive  disturbances  (subinvolution,  simple  endometritis)  the  paren- 
chymatous atrophy  rather  precedes  the  connective  tissue  proliferation,  the  latter 
being  secondary  and  to  some  extent  reparative.  The  process  of  sclerosis  effects 
not  only  the  endometrium  but  also  the  myometrium,  so  that  practically  the 
whole  wall  of  the  uterus  is  involved. 

When  the  process  follows  subinvolution,  the  uterus  remains  much  enlarged 
for  a  long  time.  At  this  stage  the  tissues  are  rather  soft  and  the  whole  uterus 
may  feel  flabby  and  atonic.  Later,  however,  the  new  connective  tissue  shrinks 
and  the  uterus  becomes  firm  and  rigid  and  smaller.  If  the  uterus  was  much  en- 
larged as  from  subinvolution,  it  would  hardly  be  reduced  to  normal  size  by  this 
shrinking.  But  in  a  uterus  only  slightl}^  enlarged,  as  from  chronic  inflammation, 
it  may  be  reduced  to  normal  size  or  even  smaller.  In  certain  cases,  this  hyper- 
plasia may  progi-ess  to  considerable  extent  in  the  myometrium  before  involving 
the  endometrium,  for  example,  following  subinvolution.  Here  the  whole  muscular 
wall  may  show  marked  sclerosis  (connective  tissue  hyperplasia  and  muscular 
atrophy)  while  the  endometrium  shows  only  simple  hypertrophic  endometritis 
(hypertrophy  of  stroma  cells  and  glands).  Later  the  endometrium  also  under- 
goes the  sclerotic  changes. 

Symptoms  and  Diagnosis. 

The  symptoms  and  signs  of  sclerosis  or  chronic  interstitial  metritis  are  those  of 
chronic  endometritis,  with  the  following  exceptions: 

1.  In  those  cases  in  which  the  sclerosis  has  progressed  so  far  tiiat  the  endonu^- 
trium  is  involved,  the  menstrual  flow  is  scanty  instead  of  profuse,  and  in  some 
cases  it  is  absent. 

2.  The  discharge  is  not  so  profuse  as  is  usually  present  in  endonictvitis  that 
produfos  n'^  much  distress. 


TREATMENT  OF  IITEHINE  SCLEROSIS  591 

3.  The  general  disturbance  and  reflex  symptoms  and  local  distress  are  usually 
more  marked  and  more  rebellious  to  treatment  than  is  endometritis.  The  fact 
that  there  is  more  general  (listiu'l)ancc  with  this  affection  may  be  due  partly  to 
the  debilitating  disease  that  preceded  and  led  up  to  the  sclerosis. 

4.  When  the  process  is  well  marked,  the  enlarged  uterus  is  firmer  in  consistency 
than  the  normal  uterus  or  than  a  uterus  which  is  the  seat  of  endometritis  only. 

5.  Usually  in  sclerosis,  the  uterus  is  more  sensitive  than  in  chronic  endome- 
tritis.    Bimanual  examination  and  sounding  cause  more  pain. 

6.  Ill  the  cervix  the  enlargement  may  be  directly  seen. 

Treatment. 

Sclerosis  is  little  amenable  to  treatment  when  it  is  well  established,  but  it  may 
to  a  large  extent  be  prevented,  and  consequently  preventative  treatment  is  very 
important.  This  consists  in  checking,  as  far  as  possible,  all  chronic  inflammatory 
and  nutritive  disturbances  in  the  uterus,  correcting  displacements  and  restoring 
the  normal  condition.  No  treatment  can  remove  the  excess  of  connective  tissue 
and  restore  the  normal  fibers.  Treatment,  however,  may  do  good  in  two  ways — 
(1)  by  removing  endometritis  and  displacement  and  laceration,  and  thus 
removing  many  of  the  troublesome  associated  symptoms,  and  (2)  by  checking  the 
further  progTess  of  the  sclerosis  or  at  least  diminishing  the  rapidity  of  such  pro- 
gi'ess. 

1.  Endometritis,  displacements,  lacerations  and  other  affections  present,  should 
be  treated  as  described  elsewhere.  In  sclerosis  of  the  cervix  (inflammatory  hyper- 
trophy) a  considerable  portion  of  the  redundant  tissue  may  be  removed  in  denuda- 
tion for  repair,  and  the  chronic  irritation  which  is  augmenting  the  sclerosis  is  at 
the  same  time  removed. 

When  sclerosis  takes  place  without  laceration  (simply  from  endocervicitis  or 
a  nutritive  disturbance)  a  portion  of  the  cervix  may  be  removed  by  excision  of 
a  wedge  of  tissue  on  each  side,  making  a  wound  resembling  a  deep  bilateral  tear. 
In  some  cases,  Ijoth  lacerated  and  non-lacerated,  it  is  advisable  to  do  a  regular 
amputation  of  the  cervix,  though  such  excessive  enlargement  in  sclerosis  is  rare. 

2.  Removal  of  the  accompanying  disturbance  has  much  to  do  with  checking 
the  spread  of  the  disease. 

An  additional  step  in  this  direction  is  the  building  up  of  the  patient's  general 
health  in  every  possible  way  and  the  removal  of  all  causes  of  pelvic  congestion. 

With  a  view  to  causing  absorption  of  the  redundant  tissue,  various  alteratives 
have  been  administered,  particularly  mercury  and  iodine  in  different  forms,  but 
without  any  decided  effect.  As  local  measures,  the  following  may  be  used:  hot 
douches,  glycerine  tampons,  and  ichthyol  to  cervix  and  as  an  intra-uterine  applica- 
tion. Skene  considered  electricity  more  useful  than  any  other  remedy  in  this 
affection.  It  may  be  tried  by  the  various  methods  mentioned  in  chapter  iii. 
After  the  menopause,  the  symptoms  may  disappear,  though  this  is  by  no  mean> 
certain  to  occur. 


592  DISEASES  OF  THE  UTERUS 

TUBERCULOSIS  OF  THE  UTERUS. 

This  term  is  applied  to  tubercular  disease  of  the  uterine  mucosa  and  myome- 
trium. When  the  tuberculosis  affects  only  the  peritoneal  coat  of  the  uterus  it 
is  classed  as  peritoneal  tuberculosis. 

Etiology. 

Tuberculosis  of  the  uterus  usually  comes  from  tuberculosis  of  the  tubes.  Oc- 
casionally it  is  due  to  infection  from  without,  in  which  case  it  may  come  from 
tuberculosis  of  the  external  genitals. 

It  may  be  produced  by  coitus  with  a  tubercular  husband,  the  tuberculosis  in 
the  husband  being  located  in  the  genito-urinary  tract.  It  is  possible  for  the 
infection  to  be  carried  in  this  way  when  the  husband  has  only  pulmonary  tuber- 
culosis, for  tubercular  bacilli  have  been  demonstrated  in  the  comparatively  healthy 
testes  and  semen  of  phthisical  patients.  Infection  conveyed  by  coitus  may  be 
first  manifested  in  the  cervix  or  in  the  body  of  the  uterus.  It  is  held  by  some  that 
such  infection  may  be  first  found  in  the  Fallopian  tubes.  Tuberculosis  of  the 
uterus  sometimes  occurs  as  a  part  of  a  general  infection,  secondary  to  pulmonary 
tuberculosis, 

Pathology. 

Tuberculosis  of  the  corpus  uteri  is  usually  associated  with  tuberculosis  of  the 
Fallopian  tubes.  Like  other  forms  of  genital  tuberculosis,  it  occurs  almost  ex- 
clusively in  patients  with  pulmonary  or  intestinal  tuberculosis. 

It  affects  principally  the  endometrium  and  usually  does  not  extend  to  the 
muscular  portion  of  the  wall  until  late.  It  may  appear  as  (a)  miliary  tubercu- 
losis, (b)  diffuse  ulcerating  tuberculosis  (caseous  form)  or  (c)  fibroid  tuberculosis — 
each  form  presenting  practically  the  same  distinguishing  characteristics  here  as 
elsewhere. 

Tuberculosis  of  the  cervix  is  very  rare  and  is  usually  associated  with  tuberculosis 
of  the  vagina.     It  appears  in  the  form  of  a  chronic  ulcer,  which  resists  treatment. 

Symptoms  and  Diagnosis. 

The  symptoms  of  tuberculosis  of  the  endometrium  are  principally  those  of  a 
severe  chronic  infected  endometritis.  There  is  nothing  particularly  distinctive  in 
the  clinical  evidences  of  tubercular  endometritis.  A  severe  endometritis  occurring 
in  a  virgin  should  arouse  suspicion  of  tuberculosis.  A  persistent  and  severe  chronic 
endometritis  in  the  presence  of  peritoneal  or  tubal  tuberculosis  or  occurring  in 
a  patient  with  phthisis,  is  possibly  tubercular.  The  diagnosis  is  made  by 
finding  tubercle  bacilli  in  the  pus  or  finding  characteristic  changes  in  the  scrapings 
from  the  uterus. 

Treatment. 

In  all  cases,  give  general  anti-tubercular  treatment.  Tuberculosis  of  the  lower 
part  of    the   cervix    alone,  calls  for   amputation  of  the  cervix  or    hysterectomy. 


ECIIINOCOCCUS  DISEASE  (.)!'  THE  UTERUS  593 

Tuberculosis  of  the  body  of  the  uterus  indicates  hysterectomy  (usually  vaginal), 
provided  there  is  no  other  involvement,  e.  g.,  advanced  phthisis  or  very  extensive 
peritoneal  involvement.  A  moderate  involvement  of  tubes  and  pelvic  peritoneum  is 
not  a  contra-indication  to  operation,  provided  the  patient  is  in  a  fair  general  condi- 
tion. In  cases  in  which  the  patient  is  not  in  fit  condition  for  radical  operation,  or 
refuses  the  same,  the  case  is  treated  on  the  same  general  principles  as  chronic 
infected  endometritis,  that  is,  by  curetment  followed,  if  necessary,  by  antiseptic 
and  astringent  applications.  Iodoform  should  be  used  freely,  in  powder  or  emulsion 
or  as  soluble  bougies.  While  a  cure  may,  in  some  cases,  follow  this  mild  treat- 
ment, its  attainment  is  very  uncertain,  and  owing  to  the  impossibility  of  deter- 
mining the  limit  of  •  the  uterine  infiltration  and  owing  also  to  the  fact  that 
the  infiltration  is  very  likely  to  spread  in  spite  of  all  treatment,  hyster- 
ectomy is  the  safer  plan  and  the  one  to  be  advised. 

SYPHILIS  OF  THE  UTERUS. 

Primary  syphilis  (chancre)  and  secondary  syphilis  (mucous  patches)  may  be 
found  on  the  cervix  uteri.  In  secondary  syphilis  there  is  probably  in  the  endo- 
metrium the  same  hyperemia  and  tendency  to  exfoliation  that  is  so  common  in 
other  mucous  membranes.  But  this  is  usually  overshadowed  by  the  other  mani- 
festations of  the  disease.  The  intra-uterine  condition  may  causes  the  symptoms 
of  mild  acute  or  chronic  endometritis.  There  may  be  menstrual  disturbances  and 
some  pain  and  discharge.     If  there  is  recent  pregnancy,  abortion  may  result. 

It  is,  however,  in  the  later  secondary  and  in  the  tertiary  stage  that  the  marked 
changes  in  the  uterus  become  apparent.  The  exact  pathological  changes  have 
not  been  entirely  worked  out,  but  they  are  supposed  to  consist  in  syphilitic  infil- 
tration (small  gummata  and  diffuse  cellular  infiltration)  of  the  endometrium 
and  probably,  to  some  extent,  of  the  myometrium — -producing  a  symptom-com- 
plex somewhat  resembUng  chronic  simple  endometritis  of  the  hypertrophic  type. 

The  most  striking  clinical  manifestation  is  repeated  abortion.  The  frequent 
abortions  in  syphilis  are,  of  course,  dependent  to  a  large  extent  on  disease  of  the 
spermatozoa  or  of  the  ovum  and  on  maternal  blood  deterioration,  but  some  of 
them  are  no  doubt  due  to,  and  many  more  are  partially  due  to,  the  diseased  con- 
dition of  the  endometrium. 

The  diagnosis  is  made  from  the  history  of  syphilis,  from  the  effect  of  treatment 
and   from  microscopic   examination  of  tissues  from  the  interior  of   the  uterus. 

The  treatment  is  the  same  as  for  chronic  endometritis,  with  the  addition  of  thor- 
ough constitutional  treatment  for  syphihs. 

ECHINOCOCCUS  DISEASE  OF  UTERUS. 

This  disease  affecting  the  uterus  is  a  curiosity,  and  yet  it  is  not  so  rare  that  it 
can  be  ignored  in  diagnosis.  Undoubted  cases  have  been  reported  in  early  hfe  and 
in  middle  life  and  later.  The  liver  is  the  organ  usually  affected  in  echinococcus 
disease.  Many  other  organs,  however,  have  been  affected,  with  or  without  co- 
incident affection  of  the  Uver,  and  among  the  organs  occasionally  affected  is  the 
uterus. 


594  DISEASES  OF  THE  UTERUS 

When  echinococcus  disease  attacks  the  uterus,  there  is  nothing  especially 
characteristic.  The  disease,  at  first,  may  resemble  chronic  endometritis  with 
hemorrhagic  tendency.  As  the  cysts  becomes  larger,  a  tumor  or  several  tumors 
become  palpable,  and  the  case  may  be  considered  one  of  uterine  fibroids.  When 
the  masses  become  still  larger,  fluctuation  may  be  detected  or  rupture  into  the 
uterine  cavity  may  take  place  with  the  discharge  of  clear  fluid  and  hooklets,  and 
daughter  cysts.  If  rupture  takes  place  into  the  peritoneal  cavity,  fatal  peritonitis  is 
probable.  The  process  may  stop  at  any  stage  and  the  lesion  undergo  partial 
absorption.  Suppuration  may  take  place  in  the  lesion,  forming  abscesses.  In 
some  cases  the  symptoms  resemble  pregnancy,  as  mentioned  by  Reed,  as  follows: 

"In  cases  of  echinococcus  infection  of  the  uterine  cavity,  the  symptoms  may 
be  essentially  those  of  pregnancy.  The  uterus  becomes  enlarged  and  softened, 
the  cervix  presenting  a  bluish  aspect.  The  womb  enlarges,  progressively  and 
symmetrically,  the  breasts  enlarge  and  may  contain  milk,  while  there  is  not  in- 
frequently reflex  disturbances  of  the  stomach.  It  is  the  occurrence  of  these  symp- 
toms which  has  generally  caused  infections  of  the  uterine  cavity  by  echinococcus 
to  be  looked  upon  as  pregnancy,  and  the  resulting  cysts  to  be  designated  as  de- 
generated ova.  In  practically  all  these  cases,  however,  the  usual  amenorrhoea 
of  pregnancy  is  absent,  while  the  patient  complains  of  more  or  less  constant  drib- 
bling of  blood  from  the  uterus.  While  this  is  true,  the  fact  must  be  recognized 
that  infection  of  the  uterine  cavity  may  coexist  with  pregnancy,  as  was  true  in 
MacNeven's  case,  in  which  a  large  echinococcus  cyst  was  expelled  intact,  during 
a  true  labor  and  immediately  preceding  the  rupture  of  the  amniotic  sac.  The 
exact  diagnosis  can  not  be  made  without  the  demonstration  of  the  hooklets." 

Echinococcus  disease  of  the  uterus  must  not  be  confounded  with  the  more  com- 
mon "hydatid  mole,"  in  which  small  cysts  of  varying  size  are  found,  and  may 
be  expelled  in  a  large  mass.  The  two  affections  are  entirely  distinct.  The  first 
(echinococcus  disease)  is  due  only  to  the  echinococcus  parasite  in  the  uterus,  while 
the  second  (hydatid  mole)  is  due  to  degenerative  changes  in  fetal  membranes— 
the  chorionic  villi  proliferating  and  becoming  distended  with  fluid  so  as  to  form 
a  mass  of  little  cysts.  This  affection  (hydatid  mole)  is  rather  frequent  and  is 
described  in  obstetric  works.  Occasionally  the  degenerating  chorionic  villi  take 
on  malignant  characteristics  and  give  rise  to  that  form  of  uterine  tumor  known 
as  chorio-epithelioma. 

The  differential  diagnosis  between  echinococcus  disease  and  hydatid  mole  is 
made  by  microscopic  examination  of  the  pathological  structures — hooklets  being 
found  in  the  first  and  chorionic  villi  in  the  second. 

The  treatment  of  echinococcus  disease  of  the  uterus  consists  in  the  rupture  and 
continual  drainage  of  all  cyst  cavities,  combined  with  the  use  of  the  antiseptics 
and  astringents  recommended  for  endometritis.  If  the  disease  persists  and  is  not 
associated  with  some  contra-indicating  lesion,  hysterectomy  is  indicated. 


595 


CHAPTER  YII. 

DISPLACEMENTS  OF  THE  UTERUS 

POINTS  IN  ANATOMY. 

The  uterus  is  situated  at  about  the  center  of  the  pelvic  cavity  (Figs.  593,  594) 
with  the  body  of  the  organ  incUned  forward,  the  long  axis  of  the  organ  being 
directed  to  a  point  above  the  symphysis  pubis,  the  direction  varying  in  different 
individuals  and  in  the  same  individual  at  different  times.  The  uterus  is  not  fixed 
in  one  position,  but  can  be  moved  easily  in  all  directions — upward,  downward, 


Fig.  593.    Section  of  a  Frozen  Body,  showing  the  usual  Position  of  the  Uterus.     {SeWheim—WeibUchen  Becl-en.) 

forward,  or  laterally.  It  is  pressed  somewhat  backward  in  the  pelvis  when  the 
bladder  is  distended  (Fig.  344)  and  somewhat  forward  wl^on  the  upper  part  of 
the  rectum  is  distended. 

It  is  seen,  therefore,  that  the  uterus  possesses  normally  a  (•f)nsideral)le  range  of 
mol^ility,  and  it  is  only  when  it  is  found  beyond  the  normal  range  that  it  can  be 
said  to  be  displaced. 


596 


DISPLACEMENTS  OP  THE  UTERUS 


What  holds  the  uterus  in  normal  position?  As  just  stated,  there  is  nothing  that 
holds  the  uterus  immovably  in  any  one  position.  By  a  combination  of  several 
factors  it  is  prevented,  ordinarily,  from  going  beyond  certain  limits,  and  is  per- 
mitted free  mobiUty  within  those  limits. 


idanlitme^. 


!•;/  I'.v,™  pr.^n 


Fig.  594.     A  View  from  in  front,  showing  the  usual  Position  of  the  Uterus.     This  is  the  same  frozen  body 
shown  in   Fig.  59.3.      (Sellheini— /re(7v?(c/(e»   liecLen.) 

The  factors  that  thus  assist  in  maintaining  the  uterus  within  normal  limits,  or 
rather  assist  in  preventing  its  remaining  permanently  beyond  the  normal  limits, 
are  the  following: 

The  Pelvic  Floor  (see  chapter  v). 

The  Sacro-uterine   Ligaments  (see  chapter  vi). 

The  Broad  Ligaments  (see  chapter  vi). 

The  Round  Ligaments  (see  chapter  vi). 

The  Normal  Weight  and  Size  of  the  Uterus. 

The  Normal  Tone  and  Fiilness  of  the  Pelvic  Tissues. 

A  large  heavy  uterus  tends  to  downward  displacement  and  ])ackwar(l  displace- 
ment more  than  one  of  normal  size.  After  the  menopause  the  atrophy  of  mus- 
cular tissue  and  absorption  of  fat  nuiy  so  interfere  with  the  normal  tone  and 


RETRODISPLACEMENT  OF  THE  UTERUS  597 

fullness  of  the  tissues  as  to  be  a  factor  in  prolapse  of  the  uterus.  The  previous 
laceration  of  the  pelvic  floor  in  these  cases  was  not  sufficient  in  itseif  to  cause  the 
prolapse. 

BACKWARD  DISPLACEMENT  OF  THE  UTERUS. 

Backward  displacement  of  the  uterus  occurs  in  two  forms — retroversion  and 
retroflexion.  In  retroversion,  the  uterus  as  a  whole  is  turned  backward,  the  re- 
lation between  the  cervix  and  the  body  remaining  the  same.  In  retroflexion,  the 
upper  part  of  the  uterus  is  bent  backward,  the  point  of  bending  lacing  about  at 
the  internal  os.  The  cervix  may  retain  its  normal  position  in  the  pelvis  but  its 
relation  to  the  fundus  uteri  is,  of  course,  much  changed. 

In  nearly  all  cases  of  backward  displacement  of  the  uterus,  there  is  both  a 
retroversion  and  a  retroflexion.  The  causes  of  these  two  displacements  are  about 
the  same,  the  symptoms  are  much  the  same,  the  treatment  is  practically  the  same 
and,  as  the  two  conditions  are  nearly  always  associated,  they  should  be  considered 
together.  "  Retrodisplacement "  is  the  term  I  shall  generally  use  in  referring  to 
a  backward  displacement  of  the  uterus.  It  includes  retroversion  and  retroflexion 
and  the  combination  of  the  two. 

ETIOLOGY. 

A  consideration  of  the  factors  concerned  in  maintaining  the  uterus  within  the 
limits  of  normal  position,  will  indicate  in  a  measure  the  causes  of  displacement. 
It  is  seldom,  however,  that  one  factor  alone  is  affected,  but  usually  several.  There 
are  various  ways  of  classifying  the  causes  of  retrodisplacement  of  the  uterus. 
The  following  classification  I  find  satisfactory  and  convenient  in  actual  work: 

A.  Causes  connected  with  labor  or  miscarriage. 

1.  Injury  of  the  pelvic  floor  and  accompanying  relaxation  of  other  support- 

ing structures. 

a.  Pelvic  floor — laceration    unrepaired,  overstretching    or    sub- 

sequent subinvolution. 

b.  Sacro-uterine  ligaments — overstretching  or  subinvolution. 

c.  Broad  ligaments,  round  ligaments  and  other  pelvic  tissues-^ 

overstretching  or  subinvolution. 

d.  Vaginal  wall — overstretching  or  subinvolution,  producing  sub- 

sequent dragging  on  cervix. 

2.  Subinvolution  of  uterus  following  labor  or  miscarriage— 

a.  Of  corpus,  due  to  infection  or  to  placental  remnants  or  blood- 

clots  retained,  or  to  an  atonic  condition  of  uterus  from  other 
cause  (anemia,  poor  pelvic  circulation). 

b.  Of  cervix,  due  to  laceration  with  infection  of  cervical  tissue,  or 

to  persistent  relaxation  or  atonic  condition  from  other  cause. 

3.  Scars  in  upper  part  of  vagina,  drawing  cervix  forward. 

4.  Getting  up  too  soon  after  labor  or  at  work  too  soon  (displacement  is 

favored  by  the  heavy  uterus  arid  the  relaxed  vaginal  wall  and  pelvic 
floor). 

5.  Constant  dorsal  position  after  labor  or  miscarriage. 


598  DISPLACEMENTS  OF  TUE  UTERUS 

B.  Non=puerperal  changes  in  uterus. 

1.  In  the  cervix  uteri. 

a.  Inflammatory  hypertrophy. 

b.  Idiopathic  hypertrophy. 

c.  Tumors. 

d.  Undue    dragging  down,  in  examinations  and  operations. 

2.  In  the  corpus  uteri. 

a.  Inflammation — increasing  tlie  weight  of  the  uterus  so  that  it 

drags  on  its  supports.  Also,  in  some  cases,  by  causing  soften- 
ing and  lacl^:  of  tone  in  the  waUs  so  tliat  the  organ  bends 
backward  more  easily  on  occasion,  and  does  not  possess  the 
tonic  elasticity  to  return  to  its  former  shape. 

b.  Tumors  in  the  anterior  wall  or  the  posterior  wall  or  in  the  in- 

terior of  the  uterus.     And  also  projecting  polypi. 

c.  Senile  atrophy. 

d.  Displacement  and  failure  to  replace,  in  examination  or  operation. 

C.  Non=puerperal  changes  in  the  supporting  structures. 

1.  Relaxation  and  stretching  from  certain  kinds  of  work. 

2.  Relaxation  and  stretching  from  faulty  dress. 

3.  Relaxation  and  stretching  from  full  bladder  (pushing  fundus  back)  or 

full  rectum  (pushing  cervix  forward) . 

4.  Stretching  by   conditions  that  increase  the  intra=abdominal   pressure 

(persistent  cough,  straining  efforts  from  stricture  of  rectum  or  from 
chronic  bladder  disease,  etc.). 

5.  Relaxation  from  general  atonic  conditions  (anemia,  etc.).      This  is  often 

accompanied  by  general  poor  support  of  the  abdominal  organs 
(splanchnotosis  or  enteroptosis) ,  due  to  repeated  pregnancies  with  poor 
recuperation  afterward  or  to  other  cause. 

6.  Stretching  in  examinations  and  operations. 

7.  Absorption  of  muscle  and  fat  in  pelvis,  due  to  wasting  disease  or  to  sen- 

ility. This  is  one  of  the  important  factors  in  prolapse  and  retrodis- 
placements  that  come  ou  after  the  menopause, 

D.  Pelvic  Tumors. 

1.  Ovarian  and  broad  ligament  tumors. 

2.  Other  tumors  arising  in  the  pelvis  or  extending  into  the  pelvis. 

E.  Pelvic  Inflammation. 

1.  Cellulitis  in  front  of  uterus  with  the  formation  of  contracting  tissue, 

drawing  {.'crvix  forward. 

2.  Peritonitis,  principally  peri-saJpiugitis  and  ixM^i-oojilioritis  forming  ad- 

hesions with  the  intestines  and  the  pelvic  wall,  which  adhesions 
contract  later  and  tend  to  drag  the  fundus  uteri  backward. 


CAUSES  OF  RETRODISPLACEMENT  5P9 

3.  Chronic  oophoritis  (follicular),  increasing  the  weight  of  the  ovary,  and 
prolapse  of  ovary,  tending  to  drag  the  uterus  backward.  Also  chronic 
salpingitis  may  cause  thickening  of  the  tubes  and  prolapse  back- 
ward and  dragging  on  fundus  uteri. 

F.   Developmental    Defects  (congenital  causes). 

1.  Short  vagina,  holding  cervix  too  far  forward. 

2.  Long  cervix  held  forward  by  the  pelvic  floor,  so  that  the  body  of  uterus 

must  be  either  in  backward  displacement  or  be  sharply  flexed  forward 
on  the  cervix. 

3.  Imperfect    descent   of   ovary,    causing   the   upper  posterior  i:)art  of  the 

broad  ligament  to  draw  backward. 


Q.  Falls. 


PATHOLOGY. 


The  essential  pathological  change  is  indicated  in  the  name  and  in  the  definition. 
The  amount  of  backward  displacement  may  be  very  conveniently  expressed  as 
first  or  second  or  third  degree.  In  retrodisplacement  of  the  first  degree,  the  fundus 
lies  just  a])out  at  the  promontory  of  the  sacrum,  in  the  second  degree  the  fundus 
lies  in  the  hollow  of  the  sacrum,  while  in  the  third  degree  it  lies  well  down  in  the 
cul-de-sac  below  the  level  of  the  internal  os  (Fig.  343).  Of  course  in  practice  all 
gradations  are  found,  from  the  normal  position  to  the  most  marked  backward  dis- 
placement. The  exact  dividing  line  between  the  cUfferent  degrees  is  not  distinct 
and  the  division  into  first  and  second  and  third  degi-ees  is  an  artificial  one  but 
very  convenient,  and  usually  cases  on  examination  may  be  easily  placed  in  one 
class  or  the  other  and  so  recorded. 

The  association  of  version  and  flexion  is  almost  constant,  a  pure  retroversion 
or  a  pure  retroflexion  being  rare.  The  most  common  lesion  is  that  shown  in  Fig. 
71 — the  uterus  is  turned  backward  far  enough  for  the  cervix  to  point  forward 
and  then  it  is  flexed  still  further.  The  cervix  is  found  pointing  more  or  le.ss 
towards  the  vaginal  orifice,  the  body  of  the  uterus  is  absent  in  front  and  is  found 
posteriorly,  at  the  promontory  or  in  the  hollow  of  the  sacrum  or  low  in  the 
cul-de-sac,  as  in  Fig.  71. 

The  broad  ligaments  are  twisted  more  or  less  and  the  return  circulation  through 
them  is  impeded.  This  causes  chronic  congestion  of  the  uterus,  engorgement, 
cellular  infiltration,  simple  endometritis  and  hypertrophy. 

If  the  displacement  follows  labor  or  abortion,  it  interferes  with  the  normal  pro- 
cess of  involution  and  causes  subinvolution.  If  it  is  accompanied  with  infection, 
it  aggi'avates  the  resulting  inflammation. 

If  it  occurs  with  laceration  of  the  pelvic  floor  (and  the  association  is  very  com- 
mon) it  increases  the  distress  of  that  condition  and  tends  to  cause  prolapse,  by 
increase  in  the  weight  of  the  uterus  and  also  by  bringing  the  point  of  the  uterine 
wedge  (instead  of  a  broad  surface)  to  press  against  the  weak  place  in  the  pelvic 
floor  (Fig.  287). 


600  DISPLACEMENTS  OF  THE  UTERUS 

The  fundus  as  it  goes  back  in  the  pelvis  frequently  takes  the  tube  and  ovary  of 
one  or  both  sides  with  it  to  some  extent.  The  ovaries  are  the  structures  the  more 
frequently  displaced,  and  one  or  both  of  them  may  be  found  in  the  hollow  of  the 
sacrum  close  to  the  displaced  fundus,  or  even  below  it  in  the  cul-de-sac. 

In  many  cases  there  has  been  inflammation  in  the  Fallopian  tubes,  resulting  in 
peritoneal  exudate  and  adhesions.  These  adhesions  fasten  the  uterus  more  or 
less  firmly  in  its  abnormal  position.  They  may  hold  the  uterus  almost  immovable, 
or  they  may  be  so  long  as  to  permit  the  uterus  much  latitude  in  movement,  but 
will  not  permit  it  to  come  entirely  forward.  Again,  if  the  adhesion  is  to  a  mov- 
able structure,  such  as  an  intestinal  coil  or  the  sigmoid,  the  uterus  may  be  brought 
forward  temporarily  but  is  soon  drawn  back  into  the  abnormal  position. 

There  is  a  rare  condition  known  as  "  retrodisplacement  with  anteflexion,"  in 
which  an  anteflexed  uterus,  while  maintaining  its  anteflexion,  becomes  turned 
backward  so  that  the  fundus  lies  in  the  posterior  part  of  the  pelvis. 

SYMPTOMS. 

The  symptoms  accompanying  retrodisplacement  of  the  uterus  are  due  princi- 
pally to  the  complications.  There  has  been  some  question  as  to  whether  uncom- 
plicated retrodisplacement  causes  any  symptoms.  It  may  be  said  that  retrodis- 
placement, as  met  with  in  actual  work,  is  rarely  without  symptoms.  Occasionall}^ 
a  uterus  is  found  in  backward  displacement  without  any  symptoms  referable 
directly  or  indirectly  to  it.  But  as  a  rule,  retrodisplacement  causes  symptoms 
or  aggravates  symptoms  due  to  some  other  disturbance. 

The  principal  symptoms  are  backache,  a  sense  of  weight  in  the  pelvis,  and 
MENORRHAGIA.  Sometimes  only  one  and  sometimes  only  two  of  these  symptoms 
are  present,  but  most  frequently  all  of  them  are  complained  of. 

In  the  menorrhagia,  the  increase  in  the  menstrual  flow  is  usually  moderate  only, 
and  more  marked  in  the  amount  than  in  the  duration.  It  is  not  always  present. 
In  a  certain  proportion  of  the  patients,  the  menstrual  flow  remains  unchanged, 
and  in  some  it  is  diminished. 

Sometimes  in  young  women,  the  menorrhagia  is  the  only  symptom.  This 
menorrhagia  from  retrodisplacement  may  be  the  cause  of  delayed  menopause. 
When  the  menorrhagia  is  pronounced  and  long  continued,  it  leads  to  severe  anemia 
and  marked  deterioration  of  the. general  health. 

The  backache  is  usually  located  low  over  the  sacrum  and  occasionally  there  is 
also  much  pain  in  the  region  of  the  coccyx  (coccygodynia).  Occasionally  the 
backache  extends  higher  along  the  spine.  It  is  more  commonly  found  in  long- 
standing retrodisplacement  and  in  the  complicated  cases — particularly  those 
complicated  with  pelvic  inflammation.  Painful  menstruation  present  is  not  so 
evidently  due  to  the  displacement,  as  is  the  menorrhagia. 

Leucorrhoea  is  usually  present,  but  is  due  to  the  displacement  only  secondarily, 
being  caused  by  the  chronic  conf!;estion  of  the  cndometriiun  and  resulting  excessive 
glandular  secretion  and  enflometrial  hyperplasia.  Bladder  and  rectal  disturbances 
are  sometimes  present,  especially  when  the  uterus  is  large  and  the  fundus  is  dis- 
placed far  down  in  the  cul-de-sac,  compressing  tlu^  rectum  or  pressing  the  cervix 
far  forward  against  the  bladdei'. 


DIAGNOSIS  OF  RETRODISPLACEMENT  601 

Sterility  is,  in  some  cases,  apparently  due  to  retrodisplacement,  though  not  as 
frequently  as  to  anteflexion  of  the  cervix  and  the  associated  conditions.  Not 
infrequently  in  a  married  woman  who  has  been  long  sterile,  pregnancy  follows 
correction  of  the  displacement.  Occasionally  the  pregnancy  follows  so  promptly 
as  to  leave  little  doubt  that  the  sterility  was  occasioned  by  the  displacement  itself 
and  not  by  any  associated  inflammatory  trouble  in  the  cervix  or  body  of  the  uterus. 

Repeated  abortion  without  apparent  cause  is  another  condition  that  should 
arouse  suspicion  of  uterine  retrodisplacement.  Reflex  symptoms,  headache  of 
\'arious  kinds  and  stomach  disturbance  or  functional  nervous  disturbance,  are 
occasionally  apparently  due  to  a  retrodisplacement,  but  on  the  whole  the  fre- 
quency of  reflex  symptoms  is  probably  exaggerated. 

DIAGNOSIS. 

The  symptoms  mentioned  are  common  to  many  diseases  and  hence  are  not  at 
all  distinctive  of  retrodisplacement.  The  diagnosis  of  retrodisplacement  must 
rest  upon  the  physical  examination.  In  examining  the  patient  it  is  found  usually 
that  the  cervix  is  lower  and  farther  forward  than  is  normal,  and  that  it  also 
points  forward. 

When  making  the  bimanual  examination  search  is  made  for  the  body  of  the 
uterus  in  its  normal  location,  by  placing  the  ends  of  the  fingers  in  the  vagina  in  the 
front  of  the  cervix  and  pushing  the  cervix  upward  and  backward  and  at  the  same 
time  pressing  the  fingers  of  the  other  hand  into  the  pelvis  from  above.  In  retrodis- 
placement it  is  not  there  (Fig.  69) .  Then  placing  the  vaginal  fingers  back  of  the  cer- 
vix and  making  bimanual  examination  (Figs.  70,  71),  a  mass  is  found  back  of  the  cer- 
vix, which  is  about  the  size  and  shape  of  the  body  of  the  uterus  and  apparently  con- 
tinuous with  the  cervix.     This  is  the  body  of  the  uterus  in  its  backward  position. 

If  the  uterus  is  in  only  the  first  degree  of  retrodisplacement  (Fig.  34.3),  the 
fundus  may  be  so  high  as  to  be  out  of  reach  of  the  vaginal  fingers,  and  yet  far 
enough  back  to  be  out  of  reach  of  the  fingers  above.  The  difficulty  is  much  in- 
creased if  the  patient  holds  the  abdominal  muscles  rather  tense.  In  these  cases 
the  body  of  the  uterus  may  sometimes  be  raised  so  it  can  be  felt  by  the  abdominal 
hand  by  pushing  up  the  cervix  with  the  fingers  in  the  vagina.  This  lifts  the  whole 
uterus — body  and  all.  If  the  displacement  is  marked  (that  is,  second  or  third 
degree)  the  fundus  can  usually  be  felt  by  the  vaginal  fingers,  back  of  the  cervix. 
When  a  mass  is  felt  in  front  or  behind  the  cervix,  it  must  then  be  determined 
whether  or  not  it  is  the  corpus  uteri.  The  following  conditions  may  cause  an 
error  in  diagnosis. 

A  tumor  in  the  anterior  wall  of  the  uterus  (Fig.  84). 

A  tumor  in  the  posterior  wall  of  the  uterus  (Fig.  392). 

A  mass  in  the  cul-de-sac,  due  to  prolapsed  ovary  or  tube  (Fig.  391)  or  to  an 
inflammatoiy  exudate  (Fig.  401)  or  to  a  tumor. 

The  differential  diagnosis  is  made  by  making  out  the  position,  size,  shape, 
consistency,  tenderness,  mobility  and  attachments  of  the  mass,  as  explained 
under  Gynecologic  Examination  (page  68). 

Determine  Mobility.  After  having  determined  that  the  body  of  the  uterus  is 
backward,  and  al^out  how  far  backward,  the  next  point  to  determine  is  whether 
or  not    it    is  freely  movable.     The  vaginal  fingers  are  pressed  avcII  in  imder  the 


602 


DISPLACEMENTS  OF  THE  UTERUS 


Fig.  595.  Attempting  to  Raise  the  Fundus  Uteri,  to  deter- 
mine whether  or  not  it  is  fixed.  This  is  also  the  first  step  in 
Bimanual  Replacement  of  the  uterus.      (Prj-or — Gynecologij.) 


ing  the  uterus  in  that  position, 
the  fundus  may  be  hf ted  past 
the  promontory  (Fig.  597), 
provided  it  is  not  otherwise 
held.  If  still  the  uterus  can 
not  l^e  raised,  it  is  probably 
adherent — i.  e.,  fixed  in  its 
false  position  by  adhesions, 
the  result  of  inflammation. 
This  probability  is  increased 
if  there  is  evidence  of  inflam- 
mation about  the  tube  on 
either  side. 

There  is  one  other  condition 
that  may  cause  the  uterus  to 
be  held  in  its  backward  posi- 


fundus  and  an  attempt  is 
made  to  lift  it  (Fig.  595).  If 
it  can  not  be  raised  from  its 
position,  it  is  fixed.  The  fixa- 
tion may  be  due  to  adhesions 
or  to  the  fundus  being  caught 
under  the  promontory  of  the 
sacrum.  To  determine  which 
condition  is  present,  catch  the 
cervix  with  the  tenaculum- 
forceps  and  pull  it  doAvn- 
ward  and  forward  (Fig.  596). 
This  maneuver  pulls  the  ute- 
rus forward  and  away  from  the 
promontory.  Then,  while  hold- 


Fig.  596.  Bimanual  Replacement.  Catching  the  Cervix  and 
Pulling  Forward  the  Uterus,  so  the  fundus  will  be  clear  of  the 
sacral  promontory.      (Kelly — Operative  Gynecology.) 


Fig.  597.       Bimanu.'il    Po] 
Uteri  past  tlic  sacral  prnmriii 


oniciit.      Raising    I  lie    I'utidiis 
y.      ( I'r.Nor —  (I'l/iicrolor/i/. ) 


tion.  Sometimes  when  the 
fundus  lies  low  in  the  cul-de- 
sac,  the  sacro-uterine  liga- 
ments produce  some  con- 
striction above  it  and  prevent 
its  return.  This  action  of 
of  the  sacro-uterine  ligaments 
is  increased  if  the  cervix 
be  strongly  pulled  upon.  This 
is  a  rare  condition  and  is  pos- 
sible only  when  the  uterus  is 
in  the  third  degi-ee  of  retro- 
displacement. 

Complications.      There    arc 


TREATMENT  OF  RETRODISPLACEMENT 


603 


several  conditions  that  frequently  accoi^-^pany  retrodisplacement  and  that  must 
be  taken  into  consideration. 

1.  Laceration  of  pelvic  nv, 

2.  Laceration  of  cervix.  v 

3.  Endometritis.  '■' 

4.  Salpingitis,  with  or  without  exudate  and  adhesions*:^.  "* 

5.  Tumors,  uterine  and  ovarian. 

The  last  two  men+ioned  may  cause  trouble  in  determining  the  exact  location 
of  the  body  of  the  uterus.  In  examining  a  patient,  do  not  stop  when  you  find  one 
lesion   but  make  a  thorough  examination  and  find  all  the  lesions  present.    . 


TREATMENT. 

If  there  are  no  symptoms,  no  treatment  is  needed.  But  the  patient  should  be 
kept  under  observation  so  that  if  symptoms  do  develop,  effective  treatment  may 
at  once  be  instituted  before  the  case  has  run  along  and  developed  complications. 

The  treatment  to  be  adopted  depends  on  whether  the  uterus  is  movable  or  ad- 
herent. 

When  the  Uterus  is  Movable. 

In  a  case  of  retrodisplacement  with  movable  uterus,the  first  step  in  the  treat- 
ment is  to  replace  the  uterus  to  its  proper  position.  There  are  two  ways  of  do- 
ing this — by  bimanual  manipulation  or  by  employment  of  the  knee-chest  posture. 

Bimanual  manipulation.  By  the  manipulation  employed  in  the  bimanual  ex- 
amination, the  uterus  is  often  replaced. 

If  it  cannot  be  replaced  by  the  ordinary  bimanual  examination  methods,  then 
catch  and  d r aw  down  the 
cervix  -with  a  tenaculum-for- 
ceps  (Fig.  596),  and  raise 
the  fundus  as  high  as  possible 
with  the  fingers  in  the  vagina. 
Then  press  the  abdominal  nand 
deeply  into  the  back  part  of 
the  pelvis,  locate  the  promon- 
tory and  then  work  along  it 
into  the  pelvis  back  of  the 
uterus  (Figs.  597,  598).  The 
fundus  uteri  is  then  brought 
forward  and  at  the  same  time 
the  cervix  is  carried  backward, 
as  shown  in  Fig.  599.  After 
bringing  the  fundus  forward, 
bend  it  well  down  over  the 
vaginal  fingers    as    shown   in 

Fig.  600,  in  order  to  take    out  pjg  595        g^,^  ^ual  Replacement.     Working  the  Ab- 

any      backward     fiexion      that  dominal  Fingers  down  over  the   sacral  promontory,  so  as 

1  ,  to   get    behind  the    fundus  uteri  and   bring    it    forward. 

may  be  present.  iFryov-dfuccoior,,.) 


604 


DISPLACEMENTS  OF  THE  UTERUS 


To  carry  out  these  manipulations  successfully,  the  abdominal  walls  must  be 
relaxed  and  the  uterus  not  very  tender.     If  the  patient  has  a  thick  layer  of  adipose 

tissue,  the  examining  fingers  some- 
times can  not  get  near  enough  to  the 
uterine  body  to  manipulate  it  satis- 
factorily. If  the  patient  holds  the 
abdominal  walls  tense,  on  account  of 
pain  or  nervousness,  the  abdominal 
fingers  cannot  reach  the  uterus.  If 
the  uterus  is  inflamed  and  tender,  the 
pressure  necessary  to  these  manipula- 
tions causes  too  much  pain. 

Knee=chest  posture.  When  the  ute- 
rus, though  movable,  cannot  be  re- 
placed b  y  t  h  e  bimanual  manipula- 
tions, the  knee-chest  posture  may  be 
used  (Fig.  469).  After  the  patient  has 
been  placed  in  this  position  (with  the 
clothing  about  waist  thoroughly  loos- 
ened) the  Sims  speculum  is  introduced 
(Fig.  470).  The  cervix  is  then  caught 
with  the  tenaculum-forceps  and  pulled 


Fig.  599.  Bringing  the  Fundus  Uteri  forward  and 
pushing  the  Cer^'ix  backward  and  upward.  (Kelly — 
Operative  Gynecology.) 


forward.  This  brings  the  fundus 
uteri  out  from  the  promontory  and 
permits  it  to  fall  forward  into  its 
proper  position.  The  cervix  is  then 
pushed  well  backward  into  the  hol- 
low of  the  sacrum,  and  a  pessary  or 
packing  is  put  in  to  hold  it  there. 

The  method  of  replacement  by 
sound  or  repositor  I  mention  only 
to  condemn.  The  sound  or  intra- 
uterine repositor  used  in  this  way  is 
dangerous.  A  uterus  that  is  not 
adherent  can  usually  be  brought  for- 
ward by  one  of  the  two  methods 
already  mentioned.  A  uterus  that 
is  adherent  could  not  be  brought 
forward  by  the  sound  or  repositor, 
and  its  use  in  such  a  case  is  liable  to 
lead  to  inflammation  or  perforation 
of  the  uterus. 

In  some  cases  the  uterus  and  ad- 
jacent tissues  are  too  tender  to  per- 
mit the  manipulations  neces.sary  for 
replacement.     In  such  a  case,    hot 


Fig.  600.  Tlie  Uterus  broiiglil  fniward  into  position. 
This  .shows  also  the  method  of  taking  the  backward 
flexion  out  of  the  uterus,  by  bending  it  firmly  forward  over 
llir  \rigiTial  finders.      (KcWy— Operative  Cynccolof/y.) 


THE  PESSARY  IN  RETRODISPI,ACEMENT  605 


vaginal  douches,  purgatives  and  the  knee-chest  posture  morning  and  evening  for 
a  few  days,  may  diminish  the  tenderness  very  much.  In  such  a  case,  after  the 
knee-chest  posture  has  been  taken  morning  and  evening  for  a  few  days,  the 
uterus  may  be  found  forward  at  the  next  examination. 

Vaginal  tamponade  with  the  patient  in  the  knee-chest  posture  or  in  the  Sims 
posture,  with  gauze  or  cotton,  every  second  or  third  day,  helps  to  restore  the  uterus 
to  its  normal  position.  Also,  in  cases  where  no  pessary  is  at  hand,  the  uterus, 
after  replacement,  may  be  held  in  place  temporarily  by  packing  the  vagina  with 
gauze  or  cotton  in  such  a  way  that  the  cervix  is  held  well  back  in  the  pelvis.  Again, 
when  a  pessary  has  to  be  removed  temporarily  for  any  cause,  the  method  of 
holding  the  uterus  by  packing  may  be  employed.  This  method  does  very  well 
for  holding  the  uterus  in  position  for  a  short  time,  but  the  packing  must  be  changed 
every  few  days,  hence  the  method  is  not  suitable  for  long-continued  use. 

The  Pessary.  After  the  uterus  has  been  replaced,  then  comes  the  problem  of 
holding  it  there.  The  most  convenient  and  efficient  device  for  this  purpose  is 
the  pessary.  In  uncomplicated  cases  this  is  often  all  that  is  needed.  The  vari- 
eties of  pessaries,  their  mode  of  action,  the  manner  of  their  introduction  and 
their  after-care  are  given  in  detail  in  chapter  iii  (see  Pessaries). 

The  Thomas,  the  Smith  and  the  Hodge  pessaries  (Fig.  452)  are  the  ones  to  be 
used  for  retrodisplacement,  according  to  the  particular  indications  given  for  each. 

In  some  cases  the  patient  is  made  fairly  comfortable  by  simple  support  of  the 
uterus  without  replacement,  such  as  is  given  by  tampons  or  by  the  inflated  ring 
pessary  (Fig.  460).  Patients  sometimes  secure  these  inflated-ring  pessaries  them- 
selves, from  friends  or  from  agents  or  through  advertisements,  and  experience  so 
much  relief  that  they  believe  themselves  cured.  And  in  some  cases  there  is  con- 
siderable benefit  persisting  for  some  time  after  the  support  is  removed,  because 
the  stretched  pelvic  tissues  have  gained  in  tone  while  the  uterus  was  supported. 
The  relief  in  these  cases  comes  from  the  relief  of  the  downward  dragging  of  the 
uterus  as  a  whole,  for  there  is  ordinarily  no  correction  of  the  retrodisplacement 
(unless  the  patient  happens  to  employ  the  knee-chest  posture  at  the  same  time). 
It  is  far  preferable  in  such  a  case  to  use  the  form  of  pessary  that  will  hold  the 
uterus  in  normal  position  and  thus  tend  to  permanent  relief. 

The  effect  just  noted  of  the  simple  support  of  the  uterus,  serves  to  show  the  im- 
portance of  the  shght  prolapse  in  these  cases  and  serves  to  show  also  that  the 
retrodisplacement,  as  a  factor  in  the  causation  of  the_  symptoms  and  as  a  factor 
to  be  considered  in  the  treatment,  is  not  of  such  exclusive  importance  as  one  would 
infer  from  the  usual  teachings  on  this  subject.  The  relief  that  follows  operative 
replacement  and  permanent  correction  of  the  retrodisplacement,  is  due  to  a  large 
extent  to  the  simultaneous  elevation  of  the  uterus  and  adnexa. 

In  some  cases  the  pessary  may  be  removed  in  a  few  weeks  and  the  uterus  will 
stay  in  position  without  further  attention.  In  other  cases  the  pessary  must  be 
worn  for  several  months,  being  removed  at  intervals,  as  explained  in  chapter  iii. 

In  a  considerable  proportion  of  cases  in  which  the  uterus  is  movable,  the  pes- 
sary is  not  satisfactory,  for  one  of  the  following  reasons: 
Laceration  of  the  pelvic  floor. 
Prolapsed  and  tender  ovary  or  tube. 
Nervousness. 


606  DISPLACEMENTS  OF  THE  UTERUS 

In  the  first  class  of  cases,  the  pessary  fails  to  keep  the  uterus  in  position.  The 
weakening  of  the  pelvic  floor  permits  the  anterior  end  of  the  pessary  to  sink 
below  its  point  of  support.  It  sinks  down  to  a  wider  part  of  the  pubic  arch  and 
then  slips  out  of  the  vaginal  opening.  The  cervix  uteri  then  sinks  forward  and 
the  fundus  goes  backward,  as  explained  on  page  330. 

When  an  ovary  has  prolapsed  into  the  posterior  cul-de-sac  the  pessary  presses 
on  it  and  causes  pain.  The  same  thing  happens  if  an  enlarged  and  tender  tube 
drops  into  this  situation,  or  if  there  is  an  inflammatory  exudate  there.  In  either 
case,  the  pessary  causes  so  much  pain  that  it  cannot  be  worn. 

There  is  occasionally  a  case  in  which,  though  the  pessary  holds  the  uterus  in 
position  and  causes  no  particular  pain,  it  makes  the  patient  uncomfortable  and 
nervous  to  such  an  extent  that  its  use  is  not  satisfactory. 

In  all  such  cases  other  measures  for  holding  the  uterus  in  position  must  be  em- 
ployed. 

Operative  treatment.  When  there  are  troublesome  symptoms  that  are  not  re- 
he  ved  by  the  measures  previously  mentioned,  operative  treatment  is  required. 
The  various  classes  of  operative  measures  are  mentioned  further  along  (page  609). 

In  order  that  the  operative  treatment  may  prove  satisfactory,  the  patient 
should  be  put  through  a  most  careful  and  thorough  pelvic  examination,  that 
the  exact  cause  of  the  persistence  of  the  displacement  may  be  accurately 
determined,  and  the  form  of  operative  treatment  selected  accordingly. 

In  a  large  proportion  of  the  patients  who  have  borne  children,  there  will  be 
found  a  relaxed  conditionof  the  pelvic  floor  and  of  the  broad  ligaments  and  sacro- 
uteiine  ligaments.  It  is  evident  that  in  such  a  case,  the  simple  bringing  of  the 
fundus  uteri  forward  and  fastening  it  there  is  only  a  small  part  of  the  necessary 
work.  The  pelvic  floor  must  be-  strengthened,  and  some  means  must  be  used  also 
to  lift  up  the  uterus  and  thus  overcome  the  prolapse  due  to  the  relaxation  of  all 
the  supports  of  the  organ.  In  many  of  these  cases  the  uterus  is  large  and  heavy 
from  subinvolution  and  is  the  seat  of  chronic  endometritis. 

""Wh&n  th6  Uterus  is  Adherent. 


When  the  fundus  uteri  cannot  be  brought  forward  by  the  methods  previously 
described  and  no  tumor  that  i^  responsible  for  the  fixation  can  be  felt,  it  is  assumed 
that  the  uterus  is  "adherent,','  i.  e.,  held  in  its  abnormal  position  by  the  products 
of  pelvic  inflammation,  affecting  ,the  tube  or  the  peritoneum  or  the  connective 
tissue.  The  fixation  may  be  so  close  that  the  fundus  cannot  be  moved  appreci- 
ably, or  it  may,  on  the  other  hand,  permit  considerable  movement  in  various 
directions,  but  not  enough  to  allp-w  the  fundus  uteri  to  be  brought  entirely  forward. 

For  the  purposes  of  treatment  it,  is  convenient  to  divide  these  cases  of  adherent 
retrodisplacement  into  two  classes — :(!)  those  in  which  the  inflammation  is  acute 
or  subacute,  and  (2)  those  in  which  it  is  chronic  or  has  practically  disappeared, 
leaving  only  the  sequelae. 

Inflammation  Acute.  Tliose  oases  present,  in  addition  to  the  retrodisplacement 
of  the  uterus,  the  usual  symptoms  and  signs  of  acute  or  subacute  pelvic  inflam- 
mation. The  symptoms  presented  by  the  patient  are  due  principally  to  the  in- 
flammation, and  the  treatment  is  at  first  directed  wholly  to  that.     The  g     eral 


ADHERENT  RETRODISI'LACEMENT  607 

and  special  measures  for  acute  pelvic  inflammation  (sec  chapter  x)  are  used  and 
continued  for  several  weeks,  until  all  acute  symptoms  have  disappeared. 

No  operation  or  other  direct  disturbance  of  the  tissues  for  the  purpose  of  bring- 
ing the  uterus  forwai'd  is  indicated  in  this  acute  stage.  All  operative  measures 
are  to  be  postponed,  except  so  far  as  such  measures  may  be  indicated  directly  by 
the  inflammation.  The  patient  is  treated  for  the  pelvic  inflammation  the  same 
as  though  she  had  no  retrodisplacement. 

When  the  inflammation  subsides,  the  troublesome  symptoms  may  disappear 
to  such  an  extent  that  no  treatment  for  the  retrodisplacement  is  required.  It 
is  the  relief  of  pain  and  discomfort  that  the  patient  seeks  and  when  this  can  be 
secured  simply  by  the  relief  of  the  inflammatory  trouble,  it  is  not  necessary  to 
disturb  the  uterus.  In  fact,  as  a  rule,  anything  in  that  direction  short  of  removal 
of  the  inflammatory  focus,  will  tend  to  stir  up  again  the  troublesome  symptoms. 

Most  of  these  patients  require  operative  treatment  later,  but  occasionally  there 
is  a  patient  who  continues  to  feel  perfectly  well  after  she  recovers  from  the 
attack  of  pelvic  inflammation — she  can  work  hard,  goes  as  much  as  she  pleases, 
and  she  is  symptomatically  a  well  woman.  It  has  been  my  experience  that  this 
permanent  or  long-continued  freedom  from  troublesome  symptoms  without  satis- 
factoiy  replacement  of  the  uterus,  occurs  more  frequently  in  the  cases  of  retro- 
displacement with  a  fixed  uterus  than  in  those  with  a  movable  uterus,  though 
it  is  not  very  frequent  in  either.  The  fixation  prevents  the  constant  downward 
dragging  (beginning  prolapse)  which  produces  a  large  part  of  the  distress  in  the 
ordinary  cases  of  large  heavy  retrodisplaced  mobile  uteri. 

Operation  is  required  however  in  a  majority  of  these  cases  sooner  or  later,  either 
because  of  a  persisting  focus  of  inflammation,  with  chronic  invalidism,  or  because 
of  the  sinking  and  dragging  of  the  heavy  retrodisplaced  uterus  on  the  damaged 
and  sensitive  adnexa  or  adjacent  structures.  In  the  cases  of  a  partially  movable 
uterus,  the  wearing  of  a  pessary  (for  example,  the  inflated-ring  pessary)  that 
holds  the  heavy  uterus  up  some,  will  sometimes  give  considerable  relief.  Such 
a  pessary  prevents  the  constant  dragging  of  the  uterus  on  its  supports  and  on  the 
sensitive  adnexa,  and  in  that  way  gives  relief,  though  there  is  no  correction  of  the 
retrodisplacement. 

Inflammation  Chronic.  In  the  chronic  cases,  fixation  of  the  retrodisplaced  uterus 
is  usually  due  to  inflammation  beginning  in  a  Fallopian  tube,  consequently  it  is 
frequently  accompanied  by  salpingitis  and  an  inflammatory  exudate  involving 
one  or  both  tubal  regions.  There  may  be  a  collection  of  pus  in  a  tube  or  in  the 
mass  of  exudate  about  the  tube,  or  there  may  be  only  a  mass  of  inflammatory 
exudate  without  pus,  or  there  may  be  only  adhesions.  If  the  previous  inflammation 
was  in  the  connective  tissue,  there  will  be  infiltration  remaining  from  the  pelvic 
cellulitis  (parametritis).  In  either  case,  the  uterus  is  found  in  an  abnormal  po- 
sition and  cannot  be  replaced  by  the  methods  previously  described. 

In  these  cases,  considerable  relief  may  be  given  by  measures  that  tend  to  allay 
the  accompanying  pelvic  inflammation  and  that  stretch  the  adhesions  and  that 
support  the  uterus  to  some  extent.  The  palliative  measures  mentioned  under 
chronic  pelvic  inflammation  (see  chapter  x)  may  be  employed.  For  support, 
the  inflated-ring  pessary  is  useful  (Fig.  460). 


608  DISPLACEMENTS  OF  THE  UTERUS 

For  stretching  the  adhesions  and  infiltrated  tissues,  in  an  endeavor  to  restore 
the  uterus  to  its  normal  position,  pelvic  massage  and  pressure  treatment  are  use- 
ful (pages  359,  364).  Cases  with  sUght  adhesions,  and  especially  cases  in  which 
the  uterus  is  held  in  its  abnormal  position  by  the  sequelae  of  a  pelvic  celluUtis 
only,  may  be  benefited  thereby,  and  in  such  cases  these  measures  may  be  given 
a  thorough  trial.  But  in  the  majority  of  cases  of  fixed  retrodisplacement,  the 
inflammatory  lesions  are  of  such  character  that  this  attempted  stretching  can  do 
no  good  and  may  do  much  harm.  The  proportion  of  cases  in  which  permanent 
relief  of  the  pelvic  distress  can  be  secured,  in  this  way,  is  very  small.  At  least, 
such  has  been  my  observation,  as  I  have  studied  this  class  of  cases  month  after 
month  and  year  after  year.  And  I  have  endeavored  to  find  for  each  variety,  the 
treatment  that  would  give  the  required  relief  with  the  least  danger  to  the  patient 
and  the  least  sacrifice  of  tissue. 

In  the  SEQUELAE  OF  CELLULITIS,  without  associated  peritoneal  involvement,  I 
expect  softening  and  stretching  of  infiltrated  tissue,  increased  mobility  of  the 
uterus,  improvement  of  the  intra-pelvic  circulation  (lymph  and  blood),  relief  of 
distressing  symptoms,  and  in  some  cases  a  complete  restoration  of  the  uterus  to 
its  normal  position. 

When  there  is  a  peritoneal  or  tubal  involvement,  as  evidenced  by  a  history 
of  attacks  of  pelvic  peritonitis  and  by  induration  in  one  or  both  tubal  regions,  little 
can  be  expected  from  stretching  or  kneading  of  the  affected  tissues.  Even  though 
all  acute  inflammation  has  apparently  long  since  disappeared,  these  tubal  anc 
peri-tubal  and  peri-ovarian  lesions  are  usually  aggravated  rather  than  improved 
by  massage  or  pressure  treatment.  As  previously  explained,  there  is  present  in 
nearly  all  these  cases  a  focus  of  active  irritation  in  the  tubes.  Nature  may  take 
care  of  this  and,  if  assisted  by  rest  and  general  measures,  may  limit  it  so  that  it 
causes  little  trouble  or  may  eradicate  it  entirely,  but  pelvic  massage  and  pressure 
treatment  are  likely  to  interfere  with  this  natural  cure  instead  of  aiding  it,  ex- 
cept as  to  hastening  the  absorption  of  outlying  masses  of  exudate. 

Operative  treatment  is  indicated  in  practically  all  cases  of  fixed  retrodisplacement, 
except  in  those  in  which  the  fixation  is  due  wholly  to  the  sequelae  of  pelvic  cellu- 
litis or  scar-tissue  about  the  vaginal  vault.  I  refer,  of  course,  to  those  cases  in 
which  troublesome  symptoms  persist  in  spite  of  treatment  for  the  pelvic  inflam- 
mation. 

The  objects  of  the  operative  treatment  are  two,  first  the  removal  of  products  of 
inflammation  and  of  damaged  organs  as  far  as  necessary  and,  second,  the  lifting 
and  bringing  forward  of  the  body  of  the  uterus  and  fastening  it. 

These  objects  may  be  accomplished  by  either  vaginal  section  or  abdominal 
section.  There  are  certain  cases  in  which  vaginal  section  is  the  preferable  method 
of  approach  and  there  are  other  cases  in  which  abdominal  section  is  clearly  indi- 
cated. Between  these  special  cases  at  each  extreme  there  is  a  large  middle  class 
of  the  chronic  cases  in  which  the  work  may  be  satisfactorily  accomplished  by 
either  route.  Some  operators  prefer  one  and  some  the  other  route.  For  my- 
self, I  think  that  in  the  majority  of  these  cases  abdominal  section  is  preferable. 
It  gives  a  much  better  chance  for  an  accurate  determination  of  what  structures 
should  be  removed  and  what  should  be  left.     It  gives  a  better  chance  also  for 


OPERATIONS  KOU  RRTRODISPT.ACEMENT  609 

complete  and  aceuvate  removal  of  diseased  structures  without  injury  to  tissues 
that  are  left.  Furthermore,  it  permits  the  fastening  of  the  uterus  well  forward 
in  such  a  way  that  it  and  its  adncxa  are  satisfactorily  elevated  as  well  as 
brought  forward. 

The  portion  of  the  operative  work  dealing  with  the  inflammatory  trouble  will 
be  mentioned  under  chronic  pelvic  inflammation  (chapter  x).  The  operative 
measures  for  the  correction  of  the  displacement,  after  the  inflammatory  trouble 
has  been  taken  care  of,  are  mentioned  below: 

Operative  Measures. 

The  operative  measures  required  in  patients  with  rctrodisplacement  of  the  uterus 
may  be  divided  into  three  gToups — (a)  measures  for  reducing  the  inflammation 
and  enlargement  of  the  uterus  and  for  restoring  the  pelvic  floor,  (h)  measures  for 
relieving  or  removing  the  pelvic  inflammation,  and  (c)  measures  for  bringing  the 
Litems  and  adnexa  forward  and  upward  and  fastening  them  there.  The  measures 
of  the  first  and  second  classes  are  given  elsewhere,  under  the  respective  diseases. 

The  operative  measures  for  holding  the  uterus  forward  are  verv  numerous, 
the  number  running  well  above  a  hundred.  There  are,  however,  certain  repre- 
sentative operations  that  may  be  mentioned  in  order  to  give  an  idea  of  the  various 
methods  of  approach  and  the  various  structures  utilized.  The  methods  of  ap- 
■roach  are  (A)  through  the  inguinal  canals,   (B)   through  a  median  abdominal 

cision,  and  (C)  through  the  vagina. 

A.  Through  the  Inguinal  Canals. 

1.  Extra-peritoneal  Shortening  of  the  Round  Ligaments  (Alexander- 

Adams  Operation).  An  incision  is  made  over  tiie  2.  '^^nal  canal  on 
each  side  and  the  round  hgament  is  isolated  and  drawn  ouu  t,ur?^iently 
to  take  up  the  slack  and  bring  the  uterus  forward.  The  ligamenLs 
are  then  fastened  in  the  canals  by  sutures.  The  peritoneal  cavity  is 
not  opened. 

a.  Operation  is  entirely  extra-peritoneal. 

b.  Utilizes  the  strong  proximal  portion  of  the  round  ligaments  for 

supporting  the  uterus. 

c.  Does  not  permit  the  breaking  up  of  adhesions. 

d.  Does  not  permit  direct  exploration  of  the  pelvis,  to  ascertain  ab- 

normal conditions  or  to  make  certain  that  the  uterus  comes 
satisfactorily  forward  without  comphcations. 

e.  Ligaments  pull    laterally    instead  of  forward  and  hence  permit 

return     of    displacement    when    there     is    much    backward 
tendency. 

2.  Inguinal  Coeliotomy  with  Shortening  of  Round  Ligaments  (Gold- 

spon  Operation) .  This  is  practically  the  same  as  the  Alexander  opera- 
tion, except  that  the  peritoneal  cavity  is  opened  on  one  or  both  "jides. 

a.  Utilizes  the  strong  proximal  portion  of  the  ligaments  for  sup- 

porting the  uterus. 

b.  Permits  partial  exploration  of  the  pelvic  cavity  and  the  breaking 

of  light  adhesions.  .    — ^. -v -r^is*r~^ 


/ 


J 


r 


610  DISPLACEMENTS  OF  THE  UTERUS 


c.  Ligaments  pull  laterally  instead  of  forward. 

d.  Has  the  disadvantage  of  median  abdominal  section  (peritoneal 

cavity  opened)  without  the  advantages  (through  exploration, 
safe  removal  of  diseased  structures,  forward  pull  of  new  liga- 
ments) . 

B.  Through  Median  Abdominal  Section.  Pertaining  to  all  the  operations  in  this 
class  are  the  advantages  of  thorough  exploration  of  the  pelvis  and  lower  ab- 
domen and  the  safe  removal  of  diseased  structures,  including  the  appendix 
when  necessary.  The  special  advantages  and  disadvantages  of  each  sub- 
method  are  indicated  below. 

1.    Fastening  the  Fundus  Uteri  directly  to  the  Abdominal  Wall. 

I.  Ventro-fixation.     The  fundus  uteri  is  scarified  and  sutured  di- 

rectly (without  intervening  peritoneum)  to  the  subperitoneal 
aponeurotic  structure  of  the  abdominal  wall. 

a.  The  uterus  is  fastened  very  firmly  forward,  so  that  there 

is  hardly  a  possibility  of  return  of  the  displacement. 

b.  Causes  serious  interference  with  the  development  of  the 

uterus  in  pregnancy,  hence  is  not  permissible  ordinarily 
in  the  child-bearing  period. 

II.  Ventro-suspension.   The  fundus  uteri  is  fastened  by  small  silk 

sutures  to  the  peritoneum  of  the  abdominal  wall.  The  idea  is 
to  secure  the  formation  of  a  band  of  tissue  which  will  hold  the 
fundus  forward  (suspend  it  from  the  wall)  but  will  not  inter- 
fere with  the  development  of  the  uterus  in*  pregnancy.  (Some 
prefer  to  pass  the  suspension  sutures  through  the  utero-ovarian 
ligaments  rather  than  directly  through  the  uterine  tissue). 

a.  Direct  forward  pull,  holding  the  uterus  well  forward. 

b.  Does  not  interfere  with  the  development  of  uterus  in  preg- 

nancy. 

c.  Uncertainty   of   ultimate   result.     The   suspending   band 

may  become  so  stretched  that  it  permits  return  of  the 
displacement  or,  on  the  other  hand,  an  unusual  amount 
of  scar-tissue  may  form  causing  a  firm  fixation  of  the 
uterus  to  the  abdominal  wall,  which  would  seriously 
interfere  with  the  pregnancy. 

d.  There  is  a  free  band  in  the  abdominal  cavity,  occasionally 
\                                  ,        leading  to  intestinal  obstruction. 

\     2.    Intra-abdominal  Shortening  of  Round  Ligaments. 
I.     Folding  of  the  round  ligaments  in  various  ways. 

a.  No  interference  with  pregnancy,  as  the  round  ligaments 

enlarge  with  pregnancy  and  undergo  involution  after- 
ward. 

b.  No  free  band  in  abdominal  cavity. 


OPERATION'S  FOR  RETRODISPI,ACEMENT  611 

c.    The  strain  comes  on  the  weak  part  of  the  ligament  near 
the  inguinal  ring.     This  is  Ukely  to  stretcii  Snd  permit 
return  of  the  displacement. 
n.  Drawing  the  round  ligaments  through  a  hole  in  the  bi-oad  liga- 
ment of  each  side  and  fastening  them  together  back  of  the 
uterus, 
a.    Secures  excellent  elevation  of  the  uterus  and  adnexa. 
I).   The  strain  falls  on  the  weak  portion  (distal  poi-tion)  of  the 
round  ligaments. 
III.  Suturing  middle  of  round  ligaments  to  tlie  peritoneum  of  the 
anterior  abdominal  wall. 

■  a.  Peritoneal  adhesions  stretch  in  time  and  are  likely  to  per- 
mit return  of  the  displacement. 
3.  Transplantation  of  Round  Ligaments  into  the  Abdominal  Wall. 
The  intra-alDdominal  portion  of  each  ligament  is  drawn  into  the 
musculo-aponeurotic  layer  of  the  al^dominal  wall  and  fastened  in  the 
median  incision  (the  median  incision  may  be  longitudinal  or  trans- 
verse). The  shortened  ligament  leaves  the  abdominal  cavity  at 
different    points  in  the  different  classes   of  operations,  as  follows: 

I.  Out  through  the  aponeurotic  wall  at  the  internal  inguinal  ring, 

and  then  to  the  median  incision  (Sandberg,  Peterson,  Mont- 
gomery, Barrett  and  others). 

a.  Utilizes  the  strong  portion  (proximal  portion)  of  ligaments 

for  supporting  the  uterus. 

b.  No  free  band  in  peritoneal  cavity. 

c.  Direction  of  pull  on  uterus  is  lateral  instead  of  forward, 

hence  the  displacement  is  likely  to  return  if  there  is 
much  backward  tendency. 

II.  Out  directly  through  the  rectus  muscle  (Gilliam  Operation). 

a.  UtiUzes  the  strong  proximal  portion  of  the  Ugaments. 

b.  Direction  of  pull  is  directly  forward,  hence  holds  uterus 

and  adnexa  well  forward  and  upward,   against  even 
strong  backward  tendency. 

c.  Can  be  used  even  when  the  round  ligaments  are  fixed  by 

inflammatory  infiltration  or  are  too  weak  to  be  used  for 
extensive  implantation. 

d.  Gives  two  free  bands  in  the  peritoneal  cavity,  which  may 

cause  intestinal  obstruction. 

III.  Out  directly  through  the  rectus  muscle,  with  the  addition  of  a 

suture  in  each  side  to  unite  the  distal  portion  of  the  round  liga- 
ment to  the  anterior  abdominal  wall  and  thus  close  the  open- 
ing through  which  an  intestinal  coil  might  slip  (Gilliam-Fergu- 
son  Operation). 

a.  Utilizes  the  strong  portion  of  the  ligaments. 

b.  Direction  of  pull  is  directly  forward. 


612  DISPLACEMENTS  OF  THE  UTERUS 

c.  Can  be  used  even  with  fixation  of  the  round  hgaments  or 

serious  attenuation  of  the  same. 

d.  No  free  band  in  peritoneal  cavity. 

e.  Operative  manipulations  more  complicated  and  time-con- 

suming than  necessary,  where  the  round  ligaments  are 

in  good  condition. 

IV.  Out  through  the  peritoneum  near  the  internal  inguinal  J'ing,  then 

along  in  the  subperitoneal  tissue  and  out  through  the  rectus 

muscle  (Gilliam-Crossen  Operation).     The  details  of    this  are 

explained  later  (Figs.  601,  602,  603). 

a.  Utilizes  tlie  strong  portion  of  the  ligaments. 

b.  Direction  of  pull  is  forward.     It  is  not  so  directly  forward 

as  in  the  regular  Gilliam  operation,  but  sufficiently  so  to 
answer  the  purpose  in  practically  all  cases. 

c.  No  free  band  in  peritoneal  cavity. 

d.  Operative  manipulations  are  few  and  quickly  executed. 

e.  Not  applicable  in  cases  of  fixation  of  round  ligaments  nor 

when  the  ligaments  are  seriously  attenuated. 

4.  Reefing  the  Broad  Ligaments. 

a.  This  lifts  the  uterus  and  adnexa. 

b.  Does  not  hold  fundus  uteri  well  forward. 

5.  Shortening    of   Sacro-uterine  Ligaments    (through   the  abdominal 

incision) . 

a.  Draws  the  cervix  uteri  well  back  and  upward  in  the  pelvis,  which 

is  an  important  consideration  in  cases  in  which  the  cervix 
comes  far  forward. 

b.  When  used  alone  it  does  not  satisfactorily  elevate  and  hold  for- 

ward the  fundus  uteri  and  adnexa.  It  is  used  when  necessary 
in  combination  with  some  anterior  operation  for  holding  the 
fundus  forward. 

C.  Through  the  Vagina.  The  vaginal  operations  in  general  have  the  advantage 
that  they  are  easily  combined  with  the  vaginal  work  previously  mentioned 
as  necessary  in  a  considerable  proportion  of  the  cases  of  retrodisplacement. 
Again,  there  is  less  handling  of  peritoneal  surfaces  and,  consequently,  less 
shock  and  less  danger  of  peritonitis. 

On  the  other  hand,  they  have  the  disadvantage  that  they  do  not  provide 
for  satisfactory  elevation  of  the  fundus  uteri  and  adnexa  nor  for  the  decided 
pull  forward  and  upward  that  is  necessary  when  there  is  a  strong  backward 
tendency.     Again,  pathological  conditions    in  the  pelvis  or  lower  abdomen 
can  not  be  so  Well  determined  nor  so  safely  and  accurately  treated. 
1.    Vagino-fixation.     The  peritoneal  cavity  is  opened  by  antoiior  vaginal 
section  and  the  fundus  uteri  fastened  forward   by  sutm-es  passing 
through  the  vaginal  wall  and  the  anterior  surface  of  the  uterus, 
a.    Fixes  the  fundus  uteri  well  forward  and  throws  the  cervix  back- 
ward. 


Ol'KRA'riOXS    I"(il<    KI'.TKdDlSI'LACK.MIiNT  613 

D.  Does  not  provide  for  satisfactory  elevation  of  the  uterus  and 
adncxa. 

c.  I'ncertainty  of  ultimate  result.  As  formerly  carried  out  it  caused 
serious  trouble  in  pregnancy.  Improvements  in  the  technique 
have  lessened  this  danger,  but  have  not  eliminated  it  entirely. 
When  the  uterus  is  fastened  forwartl  securely  enough  to  in- 
sure its  staying  there,  an  excessive  amount  of  scar  may  forr: 
and  cause  trouble  in  pregnancy.  On  the  other  hand,  when  the 
operation  is  so  conducted  as  to  practically  eliminate  this 
danger,  the  fixation  is  likely  to  be  insecure  and  there  may  be 
return  of  the  displacement. 

2.  "S'esico-fixatiox.     The  peritoneal  cavity  is  opened  by  anterior  vaginal 

section  and  the  fundus  uteri  is  brought  forward  and  sutured  to  the 
vesical  peritoneum. 

a.  Fundus  brought  well  forward. 

b.  Does  not  provide  for  satisfactor}'  elevation  of  the  uterus  and 

adnexa. 

c.  The  peritoneal  adhesions  are  likely  to  stretch  and  permit  return 

of  the  displacement. 

3.  Shortening  the  Round  Ligaments  through  Vaginal  Incision,  by 

folding  them  in  various  ways. 

a.  Brings  fundus  uteri  forward. 

b.  Does  not  provide  for  satisfactory  elevation  of  uterus  and  adnexa. 

c.  Uterus  is  suspended  by  the  weak  portion  (distal  portion)  of  the 

ligaments. 

d.  Direction  of  pull  is  lateral  instead  of  forAvard. 

4.  Anterior  Coaptation  of  the  Broad  Ligaments.     The  bladder  is  sepa- 

rated from  the  uterus,  as  in  anterior  vaginal  section,  and  then  the 
strong  tissues  in  the  lower  part  of  each  broad  ligament  are  brought 
together  in  the  median  line  in  front  of  the  cervix  and  sutured  there. 
This  operation. promises  much,  both  in  cases  of  retrodisplacement  and 
in  prolapse  of  the  uterus.  It  is  a  comparatively  new  operation,  but 
there  are  already  several  modifications.     Its  effects  are  as  follows: 

a.  Cervix  is  elevated  and  held  well  back  in  the  pelvis.     This  is 

sufficient  in  some  cases  to  keep  the  fundus  uteri  forward  and 
to  lessen  the  dragging  sufficiently  to  relieve  the  symptoms. 

b.  It  does  not  strongly  elevate  the  fundus  and  adnexa. 

c.  Like  the  other  vaginal    operations,  it  fails    to  provide  for  the 

thorough  exploration  and  operative  treatment  of  pathological 
conditions  in  the  pelvis  and  lower  abdomen. 

5.  Shortening    of    Sacro-uterine   Ligaments  through   a   Posterior 

Vaginal  Incision. 

a.  Draws  cervix  well  back  and  upward  and  throws  fundus  forward. 

b.  Does  not  satisfactorily  elevate  the  fundus  uteri  and  the  adnexa. 

c.  Tubal  and  appendiceal  complications  cannot  be  so  satisfactorily 

determined  nor  so  accurately  treated. 


614  displacements  of  the  uterus 

6.    Posterior  Vaginal  Section,  with  packing  of  cervix  back  to  form 

ADHESIONS    (PrYOr). 

a.  Cervix  is  fastened  well  backward  and  upward  and  the  fundus 

pushed  forward. 

b.  Very  uncertain  as  to  whether  satisfactory  posterior  fixation  of 

the  cervix  will  be  secured.  It  may  be  tried  when  the  cul-de- 
sac  is  opened  for  other  cause.  The  packing  may  be  used  ad- 
vantageously when  the  sacro-uterine  ligaments  are  shortened 
by  vaginal  section. 

c.  Does  not  provide  for  satisfactory  elevation  of  the  fundus  uteri 

and  adnexa. 

Choice  of  Operation. 

As  to  what  operation  is  preferable  in  a  particular  case,  that  depends  on  the 
conditions  present  in  that  case. 

When  the  uterus  is  freely  movable  and  stays  forward  well  with  a  pessary,  but 
the  wearing  of  the  pessary  is  not  satisfactory  because  of  tenderness  or  nervousness 
or  other  discomfort,  the  uterus  may  be  held  forward  by  the  extra-peritoneal 
shortening  of  the  round  ligaments  (Alexander-Adams  Operation)  or  by  vesico- 
•ixation.  I  think  the  former  is  preferable  usually  because  it  gives  better  elevation 
of  the  uterus  and  adnexa  and  also  gives  a  more  permanent  forward  fastening.  The 
field  of  either  of  these  operations  is  very  limited,  for  most  of  the  cases  in  which  they 
are  efficient  may  be  satisfactorily  treated  with  pessaries.  When  there  is  so  much 
disturbance  that  a  pessary  is  not  satisfactory,  there  is  usually  some  intra-ab- 
dominal condition  that  can  be  more  satisfactorily  handled  by  abdominal  section 
which  permits  thorough  exploration  and  direct  treatment. 

In  those  cases  in  which  al:)dominal  section  is  required,  there  conies  the  question 
as  to  "Which  is  the  preferable  method  of  fastening  the  uterus  forward  after  the 
abdomen  is  open?  "  The  answer  to  this  depends  on  the  conditions  within  the  pelvis. 
These  conditions  vary  widely  in  different  cases  of  retrodisplacement,  and  in  order 
to  handle  the  cases  intelligently  they  must  be  grouped  into  classes  representing 
the  principal  pathological  conditions.  Then,  for  each  class,  that  operation  should 
be  selected  which  best  meets  the  requirements  of  that  class. 

This  definite  classification  of  the  cases  of  retrodisplacement,  with  a  clear  compre- 
hension of  the  obstacle  to  be  overcome  in  each  class,  I  consider  a  very  important 
matter  and  one  that  must  receive  much  additional  study  before  the  subject  is 
thoroughly  understood. 

The  matter  of  classification  and  the  adaptation  of  the  operative  measures  to 
the  special  conditions  present  in  these  different  classes,  is  presented  at  some  length 
in  a  recent  article  of  mine.* 

In  respect  to  the  conditions  present  in  the  ])el\-is,  tlu>  cases  niay  be  divided  into 
four  classes,  as  follows: 

*  The  Preferable  Metliod  of  yVntcrior  Fixation  of  tlic  Uterus  When  the  Abdomen  is  Open. 
The  President's  Address,  St.  Louis  Oljstetrical  and  Gynecologi(vil  Society.  H,  S,  Crossen,  M,  D, 
Journal  of  American  Medical  Association,  May  4,   H)07. 


CHOICE  OF  OPERATION  FOR  RETRODISPLACEMENT 


615 


1.  Those  in  which  the  round  ligaments  and  adjacent  tissues  are  freely  movable. 

2.  Those  in  which  the  round  ligaments  and  adjacent  tissues  are  fixed  by  inflam- 
matory infiltration  or  other  condition. 

3.  Those  in  which  the  cervix  Ues  so  far  forward  that  the  axis  of  t)ie  uterus  still 
lacks  the  normal  anterior  direction  even  when  the  fundus  is  brought  into  the  front 
part  of  the  pelvis. 

4.  Those  in  which  there  is  so  much  inflammatory  infiltration  and  contraction 
of  the  posterior  part  of  the  broad  ligaments,  that  the  uterus  can  not  be  brought 
entirely  forward,  without  danger  of  serious  injury  to  important  structures. 


In  each  class  the  particular  operative  measure  best  suited  to  that  class  must  be 
chosen.  The  preferable  operative  measures  for  each  of  the  various  classes  is  dis- 
cussed in  the  article  previously  mentioned.  From  this  same  article  I  quote  the 
follo\ving  description  of  the  operation  which  I  find  most  useful  in  the  cases  of  the 
first  class.  It  is  the  Gilliam-Crossen  Operation  mentioned  in  the  preceding  clas- 
sification of  operative   measures. 

"1.  The  special  work  for  which  the  abdominal  cavity  was  opened  having  been 
completed,  the  left  rovmd  ligament  is  grasped  with  an  ordinary  tenaculum-forceps, 
about  1-2  inches  from  the  uterus.  The  right  ligament  is  caught  in  a  similar  man- 
ner with  another  forceps,  and  then  any  retractors  that  are  in  the  way  are  removed 
from  the  abdominal  wall.  The  giasping  of  the  ligament  of  each  side  with  the 
tenaculum-forceps  facilitates  the  subsequent  manipulation  of  the  ligaments,  after 
the  removal  of  the  retractors  which  expose  the  pelvic  cavity. 

"2.  The  point  of  the  puncturing  tenaculum-forceps  (Fig.  601)  is  entered  in  the 
left  side  of  the  wound,  just  beneath  the  upper  sheath  of  the  rectus  muscle  and 
about  one  inch  above  the  pubic  bone.  It  is  passed  outwarrl  just  beneath  the 
sheath  for  an  inch  and  then  the  point  is  directed  downward  and  made  to  punc- 
ture the  rectus  muscle  and  posterior  sheath,  but  not  the  peritoneum.  Guided 
by  the  fingers  in  the  ab- 
domen, it  is  then  passed 
outwaid  between  the  pe- 
litoneum  and  the  apo- 
neurosis to  a  point  about 
one  inch  from  the  in- 
ternal inguinal  ring, 
where  it  is  made  to  pen- 
etrate   the    peritoneum. 

The  handle  of  the  in- 
strument is  then  raised 
so  as  to  direct  the  point 
toward  the  round  liga- 
ment, and  it  is  made  to 
grasp  the  ligament  and 
overlying  peritoneum 
about  1-2  inches  from  the 
Uterus  (Fig.  602). 


Fig.  601.  The  Puncturing  Tenaculum-Forceps.  The  instrument  is 
strongly  made  and  slender,  and  is  designed  to  pass  easily  through  the 
tissues  of  the  abdominal  wall,  to  penetrate  the  aponeurosis  and  peri- 
toneum at  any  desired  point,  to  grasp  the  round  ligament  firmly  with- 
out bruising  it,  and  to  return  through  the  wall,  bringing  the  ligament 
along  the  new  canal.  (Crossen— Journal  of  American  Medical  Associa- 
tion.) 


616 


DISPLACEMENTS  OF  THE  UTERUS 


"  In  the  class  of  cases  under  consideration,  the  ligament  and  peritoneum  are 
usually  so  stretched  and  lax  that  they  are  easily  drawn  into  the  new  canal  as  a 
small  cord.  If  the  ligament  is  unusually  thick  or  if  the  peritoneum  is  so  thickened 
that  it  probably  will  not  pass  easily  into  the  forceps  canal,  a  window  may  be 
snipped  in  the  peritoneum  in  front  of  the  ligament  and  the  ligament  alone  grasped 
and  brought  into  the  canal. 

"3.  The  forceps  is  then  withdrawn,  bringing  the  ligament  with  it  into  the  forceps- 


Fig.  602.  The  Puncturing  tenaeulum-forceps  Introduced  Through  the  Wall,  as  de- 
scribed, and  grasping  the  round  ligament.  In  introducing  the  forceps  through  the  wall, 
the  point  is  carried  along  the  course  indicated  by  tlie  dotted  line  a  to  b  in  the  small 
sketch  in  the  corner.  Notice  that  the  puncture  through  the  strong  musculo-aponeurotic 
wall  is  made  at  the  rectus  muscle,  while  the  puncture  through  the  peritoneum  is  made 
at  b,  which  is  near  the  internal  inguinal  ring.  The  distance  from  b  to  the  internal  ring 
is  so  short  (about  one  inch)  that  no  puckering  suture  is  necessary.  This  point  is 
further  explained  in  Fig.  603.      (Crossen — Journal  of  American  Medical  Association.) 


track  and  out  at  the  al:)dominal  wound  (Fig,  603).  The  loop  of  ligament  brought 
out  is  now  caught  and  held  by  an  ordinary  tenaeulum-forceps,  while  the  right  liga- 
ment is  brought  out  in  a  similar  manner  with  the  puncturing  tenaeulum-forceps. 
After  the  ligaments  are  brought  into  position  the  tension  is  adjusted.  It 
may  be  necessary  to  bring  out  a  little  more  of  the  proximal  portion  or 
a   little    more    of    the    distal    portion,    the    former  to  bring  .  the    fundus   well 


CHOICE  OF  OPERATION  FOR  RETRODISPLACEMENT 


617 


forward  and  the  latter  to  close  effectively  any  space  that  may  exist  be- 
tween the  distal  portion  and  the  parietal  peritoneum.  By  paying  attention  to 
this  latter  point  the  peritoneal  puncture  may  be  made  a  considerable  distance  from 
■■■;he  internal  inguinal  ring  without  leaving  any  opening  through  which  an  intestinal 


Fig.  60-3.  The  Left  Round  Ligament  Drawn  into  Place.  Notice  that  the  direction  of 
the  pull  on  the  uteru.s  is  changed  from  lateral  to  anterior.  At  the  same  time  there  is 
no  large  opening  between  the  distal  portion  of  the  round  ligament  and  the  anterior  ab- 
dominal wall  requiring  a  suture,  as  in  the  regular  Gilliam-Ferguson  operation.  The 
distance  from  the  peritoneal  exit  of  the  new  ligament  to  the  lateral  edge  of  the  peri- 
toneal cavity  at  thi.s  level  i.s  so  small  (represented  in  the  corner  sketch  in  Fig.  602  by  the 
distance  from  b  to  the  internal  inguinal  ring)  that  it  is  closed  by  moderate  traction  on  the 
distal  portion  of  the  round  ligament  loop  appearing  in  the  wound.  If  it  is  desired  to  bring 
the  uterus  farther  forward  the  pro.ximal  portion  of  the  ligament  is  pulled  on.  If  the 
peritoneum  becomes  tense  before  there  is  sufficient  tension  on  the  round  ligament  to  bring 
the  uterus  well  forward,  the  peritoneum  over  the  ligament  loop  may  be  incised  and  the 
ligament  itself  grasped  and  drawn  out  as  desired.  (Crossen — Journal  of  American  Medi- 
cal Association.) 


coil  might  slip.  If  doubtful  on  this  point,  the  forceps  may  be  carried  to  within  half 
an  inch  of  the  ring  or  even  practically  to  the  ring  before  puncturing.  The  peri- 
toneum, being  freely  movable  on  account  of  the  loose  subperitoneal  tissue,  is  drawn 
inward  and  puckered  when  the  proximal  portion  of  the  ligament  is  drawn  tense  to 


618 


DISPLACEMENTS  OF  THE  UTERUS 


bring  the  uterus  forward.  This  brings  the  peritoneal  exit  near  the  aponeurotic 
exit  of  the  new  ligament,  beneath  the  rectus  muscle.  The  direction  of  the  new 
ligament  therefore  is  forward,  practically  the  same  as  in  the  Gilliam  operation. 

"4.  The  ligaments  are  then  fastened  in  their  new  position.     If  long  enough,  the 
loops  are  overlapped  in  the  median  line  and  fastened  to  each  other  and  to  the  upper 


Fig.  604.  The  Use  of  the  Puncturing  Tenaculum-forceps  in  the  regular  Gilliam-Fergu- 
son  Operation.  The  puncture  is  made  directly  through  the  upper  sheath,  the  rectus 
muscle,  the  lower  sheath  and  the  peritoneum,  and  the  ligament  is  grasped  and  brought  out 
—the  puckering  suture  having  been  previously  passed,  .\fter  the  ligament  is  brought 
out  as  desired,  the  puckering  suture  is  tied,  thus  closing  the  opening  at  the  side  between 
the  distal  portion  of  the  round  ligament  and  the  anterior  abdominal  wall.  (Crossen — 
Journal  of  American  Medical  Association.) 

sheath  of  the  rectus.  If  not  long  enough  to  reach  to  the  median  line,  thej-  are 
fastened  securely  in  the  forceps-track  by  catgut  sutures  passed  through  the  upper 
sheath  and  the  ligaments  beneath.  The  abdominal  incision  is  then  closed  in  the 
usual  way. 


By  the  method  just  detailed,  the  ligaments  may  be  transplanted  into  the  ab- 
dominal wall  very  quickly — giving  a  strong  reliable  forward  and  upward  traction 
to   the  \iterus  and  adnexa  and  without  any  free  bands  or  dangerous  adventitious 


PROLAPSE  OF  THE  UTERUS  619 

openings.  The  advantages  of  this  particular  technique  in  suitable  cases  over  the 
usual  technique  of  the  Gilliam-Ferguson  operation  is  that  it  simplifies  and  expe- 
dites the  work  by  doing  away  with  the  temporary  ligation  of  the  ligaments  and 
also  with  the  lateral  puckering  suture. 

The  puncturing  tenaculum-forceps  here  mentioned  may  be  used  also  with  ad- 
vantage in  the  regular  Gilliam-Ferguson  operation  (Fig.  604).  It  may  be  used 
also  in  those  operations  in  which  the  puncture  of  the  aponeurotic  wall  is  made 
practically  at  the  internal  inguinal  ring,  though  care  must  be  exercised  that  the 
deep  epigastric  vessels  be  not  injured." 

"  I  designed  this  puncturing  tenaculum-forceps  some  time  ago  and  after  con- 
siderable experimenting  arrived  at  the  present  form.  I  have  been  using  it  now 
for  a  year  and  have  found  it  so  convenient  and  satisfactory  that  I  thought  it 
worthy  of  presentation  as  a  useful  addition  to  our  armamentarium. 

"  I  have  used  it  both  with  the  ordinary  longitudinal  incision  and  with  the 
transverse  incision.  It  is  strong  and  slender  and  is  designed  to  pass  easily 
through  the  tissues  of  the  abdominal  wall,  to  penetrate  the  aponeurosis  and 
peritoneum  at  any  desired  point,  to  grasp  the  round  ligament  firmly  without 
bruising  it  and  to  return  through  the  wall,  bringing  the  ligament  along  the  new- 
canal.  Possibly  some  one  has  already  described  such  a  forceps  ;  if  so,  it  has 
escaped  my  notice.  Both  the  Gilliam  forceps  and  the  Barrett  forceps  are 
radically  different." 

PROLAPSE  OF  THE  UTERUS. 

Prolapse  of  the  uterus  is  that  condition  in  which  the  uterus  sinks  decidedly  below 
its  normal  level  in  the  pelvis.  It  is  known  also  as  "procidentia  uteri"  and  is  fre- 
quently referred  to  by  the  patient  as  "falling  of  the  womb." 

ETIOLOGY  AND  PATHOLOGY. 

The  causes  of  proJapse  are  practically  the  same  as  those  of  retrodisplacement 
(see  page  597) .  In  fact,  a  slight  prolapse  is  usually  the  first  step  in  retrodisplace- 
ment. 

The  uterus  normally  has  considerable  up  and  down  movement.  Respiration 
causes  movement  of  the  uterus,  which  is  noticeable  during  the  speculum  examina- 
tion, especially  with  the  patient  in  the  Sims  posture. 

There  may  be  considerable  exaggeration  of  the  usual  downward  displacement 
without  any  symptoms,  and  that  could  hardly  be  called  pathological.  The  con- 
dition is  not  called  prolapse  unless  there  is  marked  downward  displacement,  and 
this  is  almost  always  accompanied  with  backward  displacement  of  the  uterus. 

If  the  cervix  is  still  well  within  the  vagina,  the  condition  is  designated  as  pro- 
lapse of  the  FIRST  DEGREE.  If  the  cervix  protrudes  from  the  vaginal  orifice  it  is 
called  the  second  degree.  If  the  uterus  lies  outside  the  pelvis  it  is  called  the 
THIRD  degree,  or  Complete  prolapse.  See  Figs.  287,  288,  289,  290,  291,  292,  293, 
294,  295,  296. 

In  the  usual  case  of  prolapse,  the  uterus  is  found  retrodisplaced  and  low  in  the 
pelvis,  the  pelvic  floor  is  found  lacerated  and  there  is  present  more  or  less  endo- 


620  DISPLACEMENTS  OF  THE  UTERUS 

metritis  with  discharge.  The  vaginal  walls  also  are  relaxed  and  thrown  into 
folds  by  the  position  of  the  uterus,  and  may  be  found  projecting  outward  at  the 
vaginal  opening,  forming  an  anterior  or  posterior  colpocele. 

The  projecting  vaginal  wall  precedes  the  cervix  on  its  downward  journey.  If 
the  bladder  follows  the  projecting  vaginal  wall,  as  it  frequently  does  in  severe 
prolapse,  the  concUtion  is  known  as  cystocele  (Figs.  292,  293).  In  some  cases  of 
severe  prolapse,  the  anterior  rectal  wall  follows  the  projecting  posterior  vaginal 
wall,  forming  rectocele. 

The  cervix  in  many  cases  has  been  severely  lacerated  and  is  chronically  in- 
flamed and  is  the  seat  of  cystic  disease  and  of  an  irritating  discharge.  In  severe 
prolapse,  ulcers  often  appear  on  the  cervix  or  vaginal  walls,  being  due  to  irritation 
of  the  clothing  and  to  interference  with  the  circulation  of  the  prolapsed  portion. 
The  interference  with  the  circulation  may  be  due  to  two  factors — constriction  of 
the  prolapsed  portion  by  the  vaginal  opening  and  stretching  of  the  uterine  blood 
vessels  with  consequent  diminution  in  their  calibre.  All  the  ligaments  of  the 
uterus  are  stretched  until  they  give  practically  no  support,  and  the  lower  pelvis 
is  occupied  by  the  intestines  instead  of  by  the  pelvic  organs.  Sometimes  coils  of 
intestine  may  lie  in  the  cul-de-sac  back  of  the  uterus,  outside  the  vaginal  opening. 

SYMPTOMS. 

The  symptoms  of  prolapse  of  the  uterus  are  dragging  pains  in  the  back  and 
pelvis,  worse  when  walking,  some  protrusion  at  the  vulva  and  sometimes  diffi- 
culty in  urinating.  In  some  cases  the  protruding  bladder  must  be  pushed  back 
into  the  pelvis  before  the  patient  can  urinate.  Even  then  there  is  more  or  less 
residual  urine  which  is  likely  to  lead  to  cystitis.  Some  patients  complain  of 
partial  incontinence  of  urine  when  coughing  or  laughing.  In  exceptional  cases, 
it  is  this  partial  incontinence  that  brings  the  patient  to  a  physician,  and  he  must 
recognize  the  cause  or  he  will  fail  in  the  treatment. 

Examination  reveals  as  follows  in  the  different  degi*ees  of  prolapse: 

First  degree.  The  pelvic  floor  is  relaxed  and  there  is  more  or  less  protrusion 
of  the  vaginal  walls.  The  uterus  is  usually  retro  verted  and  the  cervix  is  low  in 
the  pelvis  and  far  forward,  near  the  vaginal  opening.  Coughing  or  straining 
cause  the  cervix  to  sink  lower  and  the  vaginal  walls  to  protrude  more. 

If  there  is  still  doubt  as  to  whether  the  uterus  sinks  low  enough  to  be  called  pro- 
lapse or  to  cause  symptoms,  the  patient  may  be  examined  in  the  standing  posture 
(see  page  50),  but  this  is  rarely  necessary. 

Second  degree.  The  cervix  is  found  presenting  at  the  vulva  (Fig.  288)  and  may 
be  made  to  protrude  by  bearing  down  (Fig.  289).  There  is  also  protrusion  of 
the  vaginal  walls  and  sometimes  of  the  bladder. 

The  cervix  and  vaginal  walls  may  return  into  the  pelvis  when  the  patient  is 
lying  down.  There  is  more  or  less  erosion  about  the  cervix  and  sometimes  ulcera- 
tion. 

Third  degree.  There  is  a  mass  nearly  as  large  as  the  fist  protruding  from  the 
vulva  and  lying  between  the  thighs  (Fig.  290).  It  is  covered  by  the  turned  out 
vaginal  wall  which,  from  friction  of  the  clothing,  has  liecome  dry  and  hard  re- 
sembling ordinary  epidermis.     At  the  lower  part  of  the  mass  is  the  cervix,  which 


DIAGNOSIS  OF  PROLAPSE  621 

is  represented  by  a  hard  nodule  with  an  opening  in  the  center  and  more  or  less 
erosion  or  ulceration  about  it.  The  appearance  of  the  cervix  depends  upon  how 
much  laceration  of  the  cervix  there  has  been. 

Grasping  the  mass  and  palpating  it  to  determine  its  contents,  there  is  found  a 
hard  elongated  mass— extending  upward  from  the  cervix.  Usually  the  size  and 
shape  of  the  uterus  can  be  accurately  made  out.  From  the  cervix  there  is  more 
or  less  discharge  which  may  be  clear  and  glairy,  resembling  the  white  of  an  egg, 
or  it  may  he  muco-purulent. 

If  the  l;)lad(ler  has  prolapsed  also,  it  is  felt  as  a  thick  cushion  of  soft  tissue  in 
front  of  the  hard  uterus  (Fig.  292).  To  determine  just  how  much  the  bladder  is 
displaced,  a  sound  may  be  introduced  into  it  and  the  outline  of  the  cavity  thus 
determined  (Fig.  293).  The  vaginal  wall  often  presents  spots  of  ulceration, 
especially  about  the  cervix  (Fig.  290),  and  there  is  often  much  irritation  over  the 
whole  prolapsed  mass  and  about  the  external  genitals. 

DIAGNOSIS. 

The  diseases  from  which  prolapse  must  be  differentiated  are  as  follows: 

1 .  Hypertrophy  of  cervix.  In  this  condition,  the  body  of  the  uterus  is  felt  nearly 
at  its  normal  height  in  the  pelvis.  Also  the  depth  of  the  uterus  is  increased,  the 
amount  of  increase  depending  on  the  length  of  the  hypertrophied  cervix.  Further- 
more, the  posterior  vaginal  wall  is  usually  not  pushed  down,  as  it  would  be  by  a 
prolapse  of  the  uterus,  and  the  bladder  is  usually  not  involved  in  the  projecting 
mass.     See  Figs.  298,  299,  300,  301,  302. 

2.  Tumor  or  Cyst  of  Vagina.  Anything  that  causes  the  vaginal  walls  to  swell 
over  a  limited  area  and  protrude,  may  be  mistaken  for  prolapse  of  the  uterus, 
for  example,  vaginal  cyst,  vaginal  hernia,  or  tumor  of  vaginal  wall.  In  all  these 
conditions,  by  careful  digital  examination,  the  cervix  may  be  felt  above  the  pro- 
jecting mass  and  near  its  normal  position.     See  Figs.  305,  306,  326,  327. 

3.  Tumors  of  uterus,  projecting  from  cervix.  Such  tumors  are,  of  course,  more 
or  less  pediculated  and  almost  invariably  they  are  fibroids.  In  such  cases,  there 
is  felt  near  the  vaginal  entrance,  a  mass,  which  maybe  hard  or  soft.  If  the  mass 
is  sloughing,  part  of  it  will  be  soft.  No  cervical  opening  can  be  felt  in  the  mass 
and,  by  exploring  higher  around  the  mass,  the  cervical  ring  can  be  felt  at  the 
upper  part  of  the  vagina.  If  the  tumor  is  sloughing,  there  is  usually  bleeding 
and  a  very  offensive  discharge.  Furthermore,  by  bimanual  examination,  the 
body  of  the  uterus  may  be  felt  near  its  normal  position.  See  Figs.  303,  307, 
308,  309,  310,  311,  325. 

4.  Inversion  of  uterus.  In  a  case  of  inversion,  a  large  mass,  apparently  a  tumor, 
is  felt  in  the  vagina.  The  vaginal  walls  can  be  felt  extending  up  past  the  mass. 
If  it  is  sloughing,  there  will  be  bleeding  and  a  foul  discharge.  Furthermore,  the 
body  of  the  uterus  is  not  felt  where  it  ought  to  be  (Fig.  322).  It  is  apparently 
nowhere  in  the  pelvis,  and  by  deep  bimanual  examination  a  depression  may  be 
felt  with  the  abdominal  hand  at  the  upper  end  of  the  vagina — a  cup-shaped  de- 
pression with  a  hard  margin,  where  the  body  of  the  uterus  should  be  (Fig.  323). 
Inversion  differs  from  a  tumor,  in  that  a  sound  can  not  be  introduced  far  into  the 


622  DISPLACEMENTS  OF  THE  UTERUS 

Uterus,  for  the  cavity  is  more  or  less  obilterated  (Fig.  324).     See  also  Figs.    304, 
312,  313  to  321,  325. 

TREATMENT. 

The  means  of  treatment  may  be  divided  into  two  classes — palliative  and  cura- 
tive. 

Palliative  Measures. 

The  palliative  measures  make  the  patient  more  comfortable,  by  relieving  the 
irritation  which  cases  the  ulceration  and  bj^  diminishing  the  dragging  on  the  uterine 
supports. 

1.  Treatment  of  the  ulceration  and  erosion,  and  reduction  of  the  mass.  All  se- 
cretion should  be  cleansed  from  the  extruded  mass  and  from  the  adjacent  sur- 
faces. Areas  of  ulceration  or  erosion  should  be  touched  "uith  some  astringent 
silver  preparation  or  with  10%  copper  sulphate  solution,  and  dusted  with  an 
antiseptic-astringent  powder. 

The  mass  should  then  be  anointed  with  an  antiseptic  ointment  and  reduced 
within  the  pelvis.  By  bimanual  manipulation,  the  backward  displacement  should 
be  corrected  as  far  as  possible,  the  fundus  being  brought  forward  and  the  cervix 
pushed  far  back  in  the  pelvis. 

2.  Pessaries  and  Tampons.  The  next  step  is  to  hold  the  uterus  in  the  pelvis,  as 
near  its  normal  position  as  possible.  If  there  is  enough  left  of  the  pelvic  floor  to 
retain  a  pessary,  that  should  be  tried. 

The  style  of  pessary  preferred  in  suitable  cases  is  that  used  for  retrodisplace- 
ment  (Fig.  452') .  for  the  object  is  to  keep  the  fundus  uteri  in  the  forward  position.  A 
long  as  the  fundus  is  forward  and  the  cervix  well  back  in  the  pelvis,  the  organ  can 
hardly  prolapse,  at  least  not  to  the  extent  of  coming  outside.  This  form  of  pessary 
is  effective  only  in  cases  of  slight  prolapse.  In  cases  of  marked  prolapse, 
the  above-mentioned  pessary  fails,  because  the  pelvic  floor  has  been  too  much 
stretched  to  hold  the  pessary  in  place.  The  anterior  end  of  the  pessary  slips  down 
to  the  vride  part  of  the  pubic  arch  and  slips  out  of  the  dilated  vaginal  opening. 
In  such  a  case,  the  inflated  ring  pessary  (Fig.  460)  will  sometimes  hold  the  uterus 
within  the  pelvis.  The  Menge  pessary  (Fig.  461)  is  sometimes  effective  where 
other  forms  of  pessary  fail. 

Where  no  form  of  intra-vaginal  pessary  will  hold  the  structures  back,  a  firm 
vaginal  packing  of  gauze  or  cotton  tampons  may  be  placed,  preferably  with  the 
patient  in  the  knee-chest  posture  or  in  Sims'  posture.  This  packing  will  hold  the 
uterus  up  temporarily  and,  by  placing  a  pad  over  the  vulva  and  liolding  it  firmly 
in  place  by  a  strong  T-bandage,  the  packing  may  be  kept  in  place  two  days.  This 
method  is  very  useful  when  treating  the  ulceration  often  found  about  the  cerv-ix, 
and  also  to  give  temporary  relief  while  preparing  the  patient  for  operation. 

3.  Cup  and  Belt  Pessary.  When  the  ordinary  pessaries  fail  to  keep  the  uterus 
within  the  pelvis  and  the  patient  refuses  curative  operative  measures,  the  cups 
pessary  with  the  abdominal  belt  may  be  used  (Fig.  462).  In  many  cases  this  make 
the  patient  fairly  comfortable,  and  with  proper  care  it  can  bo  worn  indefinitely. 
In  other  cases,  it  causes  so  much  distre.ss,  by  pressure  on  the  vaginal  walls  or 


OPERATIONS  FOR  PROLAPSE  623 

cervix  or  other  pelvic  strnetures  or  In*  the  abdominal  or  perineal  bands,  that  the 
patient  abandons  it  after  a  trial. 

4.  Rest  in  bed  and  astringent  douches.  If  the  patient  can  spare  the  time  to  go 
to  bed  and  remain  there  a  week  or  two  and  take  an  astringent  douche  two  or  three 
times  daily,  she  will  experience  considerable  relief  from  pain  and  discomfort.  This 
is  especially  important  when  there  is  ulceration  of  the  cervix  or  vagina  requiring 
treatment. 

Curative  Measures. 

These  are  all  operative  and  may  de  divided  into  two  classes — (a,)  those  that 
preserve  all  the  genital  functions  and  (b)  those  that  do  not. 

A.  Genital  Functions  Preserved.  The  uterus  and  adjacent  structures  are  re- 
stored to  approximately  normal  position  and  a'll  the  genital  functions  are  pre- 
served. 

1.  Fastening  of  Fundus  Uteri  Forward  and  Upwaiu),  and  Repair  of  Pelvic 
Floor.  The  body  of  the  uterus  is  brought  forward  and  elevated  and  the  fundus 
is  fastened  in  the  desired  position  by  one  of  the  methods  detailed  under  retrodis- 
placements.  The  pelvic  floor  is  thoroughly  repaired  by  one  of  the  methods  de- 
tailed in  chapter  v.  A  curetment  is  usually  combined  with  the  above  measures 
to  reduce  the  weight  of  the  uterus,  and  if  the  cervix  is  sufficiently  enlarged  or 
elongated,  a  part  of  it  is  amputated  (see  chapter  vi). 

All  this  may  be  done  at  one  anesthesia  or  it  may  be  divided  into  two  operations 
some  weeks  apart,  as  tliought  best  in  the  particular  case.  These  measures  are 
carried  out  in  such  a  way  tliat  the  function  of  pregnancy  and  parturition  is  not 
interfered  ^^'ith.  In  fact,  the  chance  of  pregnancy  is  increased  by  the  restoration 
of  the  uterus  to  its  normal  position. 

Practically  all  cases  of  prolapse  in  the  child-bearing  period  can  be  treated 
satisfactorily  in  this  way,  where  the  form  of  operation  best  adapted  to  the  par- 
ticular case  is  selected  and  the  proper  technique  employed.  There  are  exceptional 
cases,  but  they  are  very  rare. 

2.  Bringing  a  Strong  Portion  of  the  Lower  Part  of  Each  Broad  Lie- 
ment  in  Front  of  the  Cervix  Uteri  and  Fastening  it  There.  Tliis  is  accor 
plished  through  an  incision  in  the  anterior  vaginal  vault.  It  promises  much  in 
these  cases,  especially  when  combined  A^-ith  shortening  of  the  sacro-uterine  liga- 
ments and  operation  for  cystocele  and  repair  of  the  pelvic  floor.  It  has  not  yet 
been  long  enough  in  use  to  demonstrate  certainly  how  well  the  shortened  broad- 
ligaments  will  stand  the  strain. 

B.  Genital  Functions  Sacrificed.  The  uterus  is  removed  or  partly  removed  or 
so  placed  that  pregnancy  would  be  dangerous.  These  measures  are,  of  '-ourse, 
applicable  only  to  patients  past  the  menopause  or  in  the  menopause,  or  in  whom 
for  some  reason  pregnancy  can  not  again  occur. 

1.  Utilization  of  the  Uterus  to  Overcome  Prolapse  of  Bladder  and 
Vaginal  Walls  (Freund,  Fritsch,  Wertheim,  Landau).  Through  an  incision  in 
the  anterior  vaginal  wall,  the  bladder  is  separated  from  the  vagina  and  uterus, 
and  pushed  up.  Then  the  fundus  uteri  is  brought  forward  beneath  the  bladder 
and  fastened  securely  to  the  anterior  vaginal  wall.     The  redundant  portion  of 


624  DISPLACEMENTS  OF  THE  UTERUS 

the  anterior  vaginal  wall  is  cnt  away.  The  sutures  extend  deeply  at  the  sides  sg 
as  to  unite  the  firm  lateral  tissues  to  the  uterus  and  thus  gives  good  support  to 
the  bladder  and  other  structures  above.  This,  at  the  same  time,  turns  the  cervix 
into  the  posterior  part  of  the  pelvis  and  puts  the  vaginal  walls  on  the  stretch  and 
prevents  their  prolapse.  This  is  combined  with  a  strong  repair  of  the  pelvic  floor. 
The  special  steps  and  the  various  modifications,  it  will  not  be  necessary  to  detail  here. 

This  operation  has  several  advantages  over  hysterectomy  and,  if  the  results 
eventually  prove  lasting  and  satisfactory,  will  probably  largely  replace  it  as  a  cure 
for  prolapse. 

2.  Hysterectomy,  Either  A^\c4inal  or  Abdotminal,  with  High  Fixation 
OF  the  Vaginal  Stump,  and  followed  by  repair  of  the  pelvic  floor  either  at  the 
same  sitting  or  later. 

I  would  call  particular  attention  to  the  fact  that  hysterectomy  fails  in  many 
cases  to  cure  the  prolapse  of  pelvic  structures  unless  particular  care  is  taken  to 
fasten  the  vaginal  stump  very  high.  Without  this  precaution,  the  vagina  is  hable 
to  prolapse  again.  The  intestines  and  bladder  also  come  down  and  the  last  state 
of  the  patient  is  worse  than  the  first.  This  defect  of  the  old  vaginal  hysterectomy 
for  prolapse,  I  pointed  out,  and  illustrated  by  cases  that  came  to  me  from  other 
operators,  some  years  ago,  when  that  operation  was  at  its  height  as  a  cure  for 
this  affection.* 

Hysterectomy  as  mentioned  above,  however,  with  high  fixation  of  the  vaginal 
stump  (to  the  broad  ligament  stumps  or  to  the  anterior  abdominal  wall),  is  a  differ- 
ent proposition  and  is  effective  in  relieving  the  distressing  symptoms. 

OTHER  DISPLACEMENTS  OF   UTERUS. 

Anteflexion  of  the  Cervix  Uteri.  In  this  affection  the  cervix  uteri  is  bent  for- 
ward so  that  the  axis  of  the  cervix  is  directed  along  the  vaginal  canal  instead 
of  across  it  The  axis  of  the  cervix  forms  a  sharp  angle  with  that  of  the  corpus 
uteri,  the  point  of  bending  being  at  about  the  internal  os. 

Anteflexion  of  the  cervix  uteri  is  nearly  always  a  developmental  defect,  due  to 
the  persistence  of  the  fetal  position  of  the  cervix  uteri,  as  explained  when  considei'- 
ing  the  anatomy  of  the  uterus  at  different  periods  of  life  (see  chapter  vi). 

Almost  the  only  symptom  of  anteflexion  of  the  cervix  is  dysmenorrhoea,  and 
therefore  I  have  thought  best  to  consider  the  subject  in  detail  in  chapter  xiv, 
imder  the  ''neuro-trophic"  form  of  dysmenorrhoea. 

Anteflexion  of  the  Corpus  Uteri,  Anteversion  of  the  Corpus  Uteri  and  Lateral  Dis= 
placements  of  the  Uterus  can  hardly  be  classed  as  diseases.  They  occur  only  as 
symptomatic  disturbances  in  the  course  of  other  diseases,  and  of  themselves  do 
not  give  . '  ^e  to  symptoms  nor  require  treatment. 

Inversion  of  the  Uterus.  Tiiis  serious  and  rare  displacement  is  an  obstetrical 
affection.  It  practically  always  occurs  in  the  puerperal  state,  except  when  due 
to  the  dragging  weight  of  a  tvnnor.  When  due  to  a  tumor,  it  simply  constitutes 
one  of  the  pathological  conditions  incident  to  the  tumor  (Fig.  310,  325)  and  does 
not  require  separate  consideration. 

*  Vaginal  HystTectomy  for  I^olapsus,  by  H.  S.  Crcssen,  M.D.  Western  Medical  and 
Surgical  Gazette,  1898. 


625 


CHAPTER  Viri. 

NON-MALIGNANT  TUMORS  OF  UTERUS. 

FIBROMYOMA  OF  THE  UTERUS. 

Fibromyoma  of  the  uterus  is  a  tumor  composed  of  fibrous  and  muscular  tissue. 
It  is  called  also  uterine  "fibroid"  and  uterine  "  myoma." 

ETIOLOGY. 

The  essential  cause  is  not  known.  Some  interesting  theories  have  been  ad- 
vanced, but  they  are  still  theories  only.  The  tumor  is  analogous  to  those  growths 
Avhich  frequently  enlarge  the  prostate  in  the  male.  As  bearing  on  the  etiology  of 
uterine  fibromyomata,  it  may  be  noted  that  they  are  usually  multiple,  there  being 
but  few  exceptions  to  the  rule  that  where  there  is  one  palpable  fibroid  there  are 
many  smaller  nodules.  They  occur  most  frequently  in  middle  life  (period  of 
sexual  activity),  though  they  may  occur  at  any  age.  Again,  child-bearing 
apparently  has  no  influence  in  causing  them.  This  is  in  marked  contrast  to  carci- 
noma, particularly  carcinoma  of  the  cervix,  which  occurs  almost  exclusively  in 
■women  who  have  borne  children  or  who  have  had  some  injury  to  the  cervix. 

PATHOLOGY. 

1.  Composition.  A  fibromyoma  is  composed  principally  of  connective  tissue 
and  involuntary  muscular  tissue — the  same  tissues  that  compose  the  uterine 
wall.  In  a  small  proportion  of  fibroids  there  are  found  small  irregular  cavities 
resembling  glands  and  lined  with  epithelium.  Such  tumors  are  designated  by 
the  term  ''adenomyoma." 

2.  Relation  to  uterine  wall.  The  fibroid  starts  as  a  small  nodule  in  the  muscular 
layer  of  the  uterine  wall.  As  it  enlarges  there  usually  develops  a  distinct  capsule, 
or  layer  of  condensed  tissue,  which  separates  the  tumor  proper  from  the  normal 
uterine  wall  surrounding  it  (Figs.  605,  606,  607).  From  this  capsule  it  may  be 
easily  shelled  out,  except  when  there  has  been  inflammatory  infiltration  of  the 

■  capsule  and  tumor.  As  long  as  the  tumor  is  surrounded  l:)y  the  muscular  tissue 
of  the  wall,  it  is  known  as  an  intramural  or  interstitial  fibroid  (Figs.  605,  606, 
607.)     They  comprise  60  to  70  per  cent  of  the  cases. 

As  the  ordinary  encapsulated  tumor  gi'ows,  it  pushes  in  the  direction  of  least 
resistence,  stretching  the  muscular  tissue  around  it  and  tending  to  push  the  mus- 
cular tissue  aside.  When  it  pushes  aside  the  muscular  tissue  to  the  outer  side 
of  it  and  comes  to  lie  just  beneath  the  peritoneum,  it  is  known  as  a  subserous 
or  subperitoneal  fibroid  (Fig.  375).  They  comprise  20  to  30  per  cent  of  the 
cases. 


626 


FIBROMYOMA  OF  THE  UTERUS 


This  process  of  escape  from  the  gi-asp  of  the  muscular  tissue  may  progress,  the 
tumor  projecting  farther  and  farther  beyond  the  outUne  of  the  uterus  but  still 
covered  b}"  the  peritoneum,  until  it  is  attached  to  the  uterus  only  by  a  compara- 
tively narrow  band  of  tissue,  or  pedicle,  carrying  the  blood  vessels  and  covered 
by  peritoneum.     It  is  then  a  pediculated  subperitoneal  fibroid  (Fig.  375). 


V 


Fig.  605.      Multiple    Fibromyomata  of  the  uteras.       A.    The  divided  uterine  cavity. 
(Bishop —  Uterine  Fihromyomntn.) 


Fig.  606.  Multiple  lilirornjoinata  of  the  Uterus,  sertioned  .so  a.^  to  .show  the  relation  of  the  tumor- 
ma.«sesto  the  uterine  wall.  Tlie  enoap.«ulation  of  the  fibroid  nodules  i.s  well  .^hown.  To  the  extreme  left  is  a 
subperitoneal  fibroid  (not  .sectioned).  The  top  of  the  uterine  cavity  is  seen  near  the  center  of  the  left  half  of 
the  sectioned  ma.ss. 


]'t)I\TS   I\   l'Aril()I-0(JY 


62< 


In  some  cases  adhesions  to  adjufcnt  structures  are  formed,  and  through  these 
adliesions  the  tumor  may  receive  part  of  its  blood  supply.  Occasionally  the 
pedicle  of  such  a  tumor  is  severed  by  torsion  or  otherwise  and  the  tumor  is  thus 
entirely  separated  from  the  uterus  and  receives  its  blood  supply  through  the  vas- 
cular adhesions.  Such  a  tumor  is  known  as  a  detached  or  "parasitic"  or  wander= 
ing  fibroid,  and  constitutes  one  of  the  curiosities  of  pathology. 

If  a  tumor  which  is  escaping  outward  from  the  gi-asp  of  the  muscular  wall  is 
so  situated  that  it  projects  into  the  broad  ligament,  it  is  known  as  an  intra= 
ligamentary  fibroid.  If  it  projects  in  such  a  situation  that  it  raises  the  peritoneum 
behind  the  uterus  and  passes  back  of  the  peritoneum,  it  is  then  called  a 
retroperitoneal  fibroid. 

On  the  other  hand,  the  fibroid,  as  it  develops,  may  push  its  way  inward  instead 


Fig.  6^7.     A  Single  Encapsulated  Fibromyoma  of  the  uterus.      (Bishop — Uterine  Fihro- 
myomata.) 


of  outward,  and  may  come  in  time  to  lie  beneath  the  endometrium,  where  it  is 
known  as  a  submucous  fibroid  (Figs.  605,  357).  Submucous  fibroids  comprise 
about  10  to  15  per  cent  of  the  cases. 

The  submucous  fibroid  may  project  farther  and  farther  into  the  uterine  cavity, 
until  it  is  attached  to  the  uterine  wall  only  by  a  naiTOw  pedicle  (pediculated  sub= 
mucous  fibroid — Figs.  309,  325).  A  pediculated  submucous  fibroid  may  be  forced 
out  into  the  vagina  while  still  attached  to  the  uterine  wall  (Figs.  308,  309)  and 
may  in  this  way  cause  partial  or  complete  inversion  of  the  uterus  (Figs.  315,  325), 
a  fact  that  must  be  kept  in  mind  when  removing  such  a  gi-owth  l)y    operation. 

Some  fibroids,  especially  the  adenomata,  are  withf)ut  a  distinct  limiting  cap- 
sule. The  tumor  tissue  blends  directly  with  the  uterine  wall  (Fig.  608).  Such 
a  tumor  is  called  a  diffuse  fibroid.  It  may  occupy  only  a  small  area  or  may  extend 
all  the  wav  around  the  uterine  cavity. 


628 


FIBROMYOMA  OF  THE  UTERUS 


Fig.    608.       A  Diffuse  Adeno-myoma  of  the    Uterus. 
(Bla.nd-iiutton—/Ii/sterec(07ny.] 


Most  fibroids  are  found  in  the  body 
of  the  uterus,  as  indicated  in  the 
various  illustrations. 

In  a  certain  proportion  of  cases, 
the  fibroid  is  situated  in  the  cervix. 
Bland-Sutton  found   in  a  series  of 
500  cases,  that  5%  were  cervix  fib- 
roids.   These  are  more  often  single, 
and   rarely  project  into  the  cavity, 
as  the  cervical  cavity  is  small.  They 
ai'e  usually  comparatively  small, 
but  sometimes  reach  a  size  of  8  lbs. 
4.  Secondary  Changes.     Under 
composition   is   given  the   primary 
structure  of    the  various    forms  of 
fibromyoma.     In  many  cases  there 
are  found  secondary  changes  in  the 
tumor  structure.    These  changes  are 
edema,  myxomatous  degeneration, 
necrobiosis,    necrosis,   suppuration, 
cystic    degeneration,     calcification, 
malignant   degeneration    and    other  rarer    changes  (atrophy,  fatty  degeneration, 
amyloid  degeneration).     The  relative  frequency  with  which  the  more  important 
of  these  secondary  changes  has  been  noted   in  operated  cases,  is  shown   in  the 
table  on  page  655.      Necrosis  and  suppuration  are  shown  in  Figs.  609,  610  and 
611.   Cystic  change  is  shown  in  Figs.  426  and  612.     Sarcomatous  development  is 
shown  in  Figs.  613  and 
614. 

5.  Complications  and 
Associated  Diseases. 
These  are  very  numerous 
and  very  important,  for 
a  large  proportion  of  the 
deaths  and  of  the  suffer- 
ing in  fibroid  cases,  comes 
from  them.  Some  of 
these  conditions  are  due 
directly  to  the  fibroid, 
some  are  due  indirectly 
to  it  and  some  have  no 
etiological  c  o  nn  e  c  t  i  o  n 
with  the  fibroid,  ])ut  are 
only  associated  affec- 
tions. Some  of  them  can 
not  be   assigned    exclu-  .  . 

,  I'lg.  fiOD.       .Necrosis  of  ati  IiilraliKaiiu'ntary  Fibromvonia.       (llirst- 

sively  to  one  group  or  the        mseases  of  women.) 


POINTS  IN  PATHOLOGY  629 

other,  so  I  think  best  to  consider  them  all  together.  For  convenience  they  are 
divided  into  three  classes  according  to  locality — (a)  in  the  uterus,  (b)  in  adja- 
cent structures  and  (c)  in  distant  organs. 


Fig.  610.  Section  of  a  Necrotic  Fibroid.  I  saw  the  patient  in  consultation  with  Dr.  C.  O.  C.  Max. 
There  was  a  large  fibroid  extending  nearly  to  the  umbilicus,  which  had  become  necrotic  from  infection 
due  to  the  introduction  of  a  uterine  sound  by  a  midwife.  The  patient  was  in  a  desperate  condition. 
The  clinical  features  are  mentioned  briefly  on  page  660.  .\t  the  operation  we  found  that  the 
necrotic  fibroid  had  perforated  the  uterine  wall  and  was  in  contact  with  the  omentum.  This  Antero- 
posterior Section  of  the  removed  Uterus  and  Tumor  shows  accurately  the  relation  of  the  necrotic  mass 
to  the  uterine  wall.  It  was  almost  free  in  its  suppurating  bed.  Fig.  61 1  shows  the  ijcrforation  through 
the  uterine  wall. 


630  FIBROMYOMA  OF  THE  UTERUS 

a.  In  this  class  come  thickening  of  the  endometrium,  distortion   of  the  uterine 
cavity  and  displacement  of  the  uterus. 

b.  Here  are  found  salpingitis,  Iwdrosalpinx  and  pyosalpinx.     Also,  compression 
of  the   ovaries,  with   inflammation  and  sometimes  hematoma.     There  may  be 


Fig.  611.  A  Necrotic  Filiroid  I'erforatiiig  the  Uterine  Wall.  Same  specimen  as  shown  in  Fig.  610. 
The  specimen  consists  of  the  uterus  and  tumor  removed  by  total  hysterectomy.  The  patient  recovered. 
The  Perforation  here  shown  was  covered  by  adherent  omentum.  .\3  soon  as  the  omental  adhesions 
wcro  separated,  pus  from  the  suppurating  bed  in  which  the  necrotic  mass  lay  poured  into  the  peritoneal 
cavity.     Tlic  tumor  was  large  and  the  perforation  was  at  (lie  top  of  tiic  mass,  near  the  umbilicus. 


SYMPTOMS 


631 


troublesome  pressure  on  the  l^laddor  or  rectum  or  pelvic  blood  vessels.     In  some 
cases  there  is  marked  displacement  of  the  bladder  (Fig.  615). 

c.  The  changes  in  distant  oi-gans  concern  principally  the  heart  and  the  kidneys. 
These  changes  are  often  serious.  They  are  mentioned  at  some  length  below,  in 
considering  the  dangers  from  long-standing  fibroids  (sec  page  650). 


Fig.  612.       A    Large    Cystic     Fibroiiiyouia.       (KeUy— Operative 
Gynecology,) 


SYMPTOMS  AND  SIGNS, 
Symptoms. 

The  symptoms  given  by  the  patient  are,  in  the  usual  order  of  their  appearance, 
(1)  menorrhagia,  (2)  leucorrhoea,  (3)  pressure  symptoms,  (4)  pain  and  (5)  a  lump 
in  the  lower  abdomen. 

1.  Menorrhagia,     This  is  usually  the  first  disturbance  noticed,  particularly  in 


632 


FIBROMYOMA  OF  THE  UTERUS 


submucous  and  interstitial  growths.  There  is  much  variation  in  the  menstrual 
disturbance.  Usually  the  flow  is  increased,  but  sometimes  it  is  diminished. 
Emmet,  in  a  series  of  216  cases,  found  the  menstrual  flow  decidedly  increased  in 
50%,  unchanged  in  20%,  lessened  in  16%  and  irregular  in  13%. 


Fig.  613.  A  Sarcoma  Developing  in  a  Cervical  Stump.  The  pelvis  is  viewed  from  above.  Rising  from 
the  pelvis  between  the  bladder  and  the  rectum  is  a  smooth  lobulated  growth.  To  the  left  is  the  intact  and 
normal  left  ovary.  The  right  appendages  were  removed  at  the  first  operation.  The  first  operation  was 
supravaginal  hysterectomy  for  Fibromyoma.  The  original  tumor  is  shown  in  Fig.  614.  (Cullen — Journal  of 
American  Medical  Association.) 


2.  Leucorrhoea  is  usually  present  after  a  time,  especially  in  the  submucous  and 
interstitial  grov/ths.  This  is  due  to  the  accompanying  chronic  simple  endome- 
tritis. 

3.  Pressure  symptoms.     These  are  indefinite,  simply  an  indication  that  there  is 


SYM1TOM8 


633 


some  slight  disturbing  element  in  the  pelvis.     The  patient  has  some  bladder 
irritability  and  a  feeling  of  weight  in  the  pelvis.     There  is  usually  constipation. 
After  the  tumor  becomes  large,  marked  pressure  symptoms  occur. 
4.  Pain.     This  appears  later.     It  is  usually  present  as  a  backache  (lumbar  or 


e  /^ 


^^-^, 


mil , 

'slid    -Ifl'iiJ 

mrm 


Fig.  614.  The  Fibromyoma  removed  in  the  Supravaginal  Hysterectomy  mentioned  under  Fig.  613.  After 
the  development  of  the  sarcoma  in  the  cer\-ical  stump,  the  original  tumor  (supposedly  a  simple  .^ibroid)  was  sec- 
tioned as  here  shown.  Several  large  areas  of  sacromatous  degeneration  were  found,  the  most  marked  of  which 
are  indicated  by  the  letter  d.     (Cullen — Journal  of  American  Medical  Association.) 


sacral)  or  as  pain  in  the  lower  abdomen  or  as  thigh-pain  on  one  or  both  sides. 
The  pains  usually  come  and  go  at  first,  and  are  worse  when  the  patient  is  on  her 
feet  and  also  at  the  menstrual  periods. 

5.  Lump.     In  a  large  proportion  of  the  cases,  after  .some  months  or  years,  a 


634 


FIBROMYOMA  OF  THE  UTERUS 


lump  is  noticed  in  the  lower  abdomen.     If  the  mass  is  smooth,  however,  it  is 
surprising  how  large  it  will  sometimes  get  before  the  patient  notices  it.     Of  course 

a  mass  with  nodular  projec- 
tions is  usually  noticed  as  soon 
as  it  b  e  g  i  n  s  to  distend  the 
lower  abdomen.  In  a  certain 
proportion  of  cases,  the  mass 
even  when  large  is  still  too 
deeply  placed  in  the  pelvis  to 
be  appreciable  to  the  patient, 
and  in  some  cases  (small  sub- 
mucous fibroid)  the  mass  is 
not  appreciable  to  the  physi- 
cian, even  on  careful  bimanual 
,  ,      ,  examination,  though    there 

Fig.  615.     A  Large  Fibromyoma  of  the  Uterus,  which  has  drawn  u     i  i      j'  i 

the  Bladder  far  up  into  the  abdomen.     Notice  the  immense  veins        may  be    .mUCh     bleeding     and 
on    the    peritoneal     surface    of     the    bladder.      (Kelly — Operative       HistrPSS 
Gynecology.) 


Examination  Signs. 

The  diagnosis  of  uterine  fibroid  must  rest  on  the  examination  findings,  for  the 
symptoms  are  not  distinctive.  Taking  up  the  Points  as  given  in  the  Diagnostic 
Table  (pages  287,  288),  we  find  as  follows  in  the  case  of  a  fibromyoma: 

1 .  Position  of  mass.  In  the  central  part  of  the  pelvis  and  extending  from  there 
toward  one  side. 

2.  Size  of  mass.  May  be  any  size,  from  one  barely  palpable  in  the  wall  of  the 
uterus  to  a  large  tumor  filling  the  abdomen. 

3.  Shape.  Individual  tumors  are  apparently  spherical,  but  as  they  project  from 
the  uterus  or  grow  beside  each  other,  they  form  a  mass  of  very  irregular  contour, 
usually  presenting  several  distinct  bosses  or  rounded  projections  outside  the 
general  outline  of  the  mass. 

4.  Consistency.  Firm,  usually  much  harder  than  the  adjacent  uterine  wall. 
Occasionally,  part  of  a  tumor  will  undergo  cystic  change — but  even  then  the 
greater  part  of  the  mass  is  usually  solid. 

5.  Tenderness.  Not  tender,  unless  incarcerated  in  pelvis  or  pressing  on  nerves 
or  accompanied  with  inflammation. 

6.  Mobility.  The  tumor  and  uterus  are  movable  together  up  and  down  in  the 
pelvis,  but  they  are  not  movable  separately  unless  the  fibroid  is  pediculated. 

7.  Attachment.  Attached  in  the  uterine  region  and  free  elsewhere,  unless 
complicated.  A  subperitoneal  fibroid  with  a  long  pedicle  may  be  mistaken  for  a 
growth  from  some  of  the  abdominal  organs.  The  pedicle  connecting  the  mass 
with  the  uterus,  can  usually  be  felt  on  deep  bimanual  palpation.  In  a  difficult 
case,  a  useful  expedient  is  to  have  an  assistant  grasp  the  tumor  and  draw  it  up 
into  the  abdomen  while  the  examiner  makes  deep  bimanual  palpation  in  search 
of  the  pedicle,  which  is  thus  made  tense  and  is  easier  felt  (Fig.  103). 

8.  Apparent  point  of  origin.     From  uterus.     Occasionally  a  fibroid  becomes 


DIAGNOSIS  635 

detached  from  the  uterus  or  has  such  a  long  pedicle  that  it  appears  free,  but  that 
is  rare. 

9.  Relation  to  uterus.  Intimately  connected  to  the  uterus,  growing  from  the 
same.     May  be  from  any  part,  usually  from  body. 

10.  Position  of  uterus.  May  be  displaced  in  any  direction,  may  be  in  normal 
position. 

11.  Size  of  uterus.  Enlarged  by  tumor  in  wall,  cavity  lengthened.  But  do 
not  explore  with  sound  unless  necessary. 

12.  Shape  of  uterus.  Usually  distorted  and  presenting  one  or  more  distinct 
projections.     Occasionally  symmetrically  enlarged. 

13.  Consistency  of  uterus.  Uterine  tissue  proper  of  normal  consistency,  but 
fibroid  nodules  harder.  Occasionally  a  tumor  will  present  a  softened  area  (ede- 
matous) or  a  fluctuating  area  (cystic).  Occasionally  the  cervix  is  softened  by 
edema  incidental  to  impaction  in  the  pelvis,  but  there  is  rarely  enough  softening 
to  imitate  pregnancy. 

14.  Tenderness  of  uterus.  Not  tender  on  palpation  or  movement,  except  when 
complicated. 

15.  Mobility  of  uterus.  Movable  in  pelvis  with  tumor,  unless  tumor  is  so  large 
as  to  fill  pelvis  or  so  situated  as  to  put  uterine  supports  on  stretch,  or  complicated 
by  pelvic  inflammation  or  another  tumor.  Uterus  and  tumor  movable  together, 
but  not  separately  unless  tumor  is  pediculated. 

16.  Discharge  from  uterus.  Usually  there  is  a  discharge,  due  to  complicating 
endometritis  (simple  or  infected). 

17.  Discoloration  of  cervix  or  vagina.  None,  except  what  can  be  accounted 
for  by  evident  pressure  on  vessels. 

18.  Relation  of  mass  to  tube  and  ovary.  No  connection  with  tube  or  ovary, 
except  possibly  lying  against  them.  Tube  and  ovary  of  each  side  may  be  felt  (if 
abdominal  wall  not  too  tense),  unless  mass  is  so  large  or  so  situated  as  to  obscure 
them. 

19.  Helation  to  pelvic  wall.  No  connection  with  pelvic  wall,  except  when  large 
enough  to  extend  to  it  or  when  complicated  by  inflammation  or  another  tumor. 

20.  Relation  to  vaginal  wall.  Depends  on  situation  of  tumor,  usually  well 
above  wall.  When  in  cervix,  the  mass  lies  against  vaginal  wall,  just  beneath  ex- 
amining finger. 

21.  Bladder.  May  be  compressed  by  mass  and  distorted,  or  maybe  pulled  up 
into  abdomen  (Fig.  615). 

22.  Rectum.     May  be  pressed  upon  to  such  an  extent  as  to  cause  hemorrhoids. 

23.  INIass  elsewhere.  In  addition  to  the  main  tumor  springing  from  the  uterus, 
one  or  more  other  nodules  may  usually  be  felt  in  some  other  part  of  the  uterus. 

24.  Colon  or  small  intestine  in  front.  Not  unless  retroperitoneal  or  complicated 
by  adhesions. 

25.  Outline  of  dullness.  Dullness  over  mass  and  resonance  elsewhere,  unless 
complicated  by  ascites. 

26.  Shifting  outline  of  dullness.  No  change  in  outline  of  dullness  on  change  of 
position  of  patient,  except  when  complicated  by  ascites  or  when  tumor  rolls  some 
in  the  abdomen. 


636  FIBROMYOMA  OF  THE  UTERUS  J 

27.  Hard  masses  within  a  cystic  mass.  Nothing  hke  this,  simulating  fetal  parts 
in  the  uterus,  except  rarely  when  complicated  by  ascites.  One  case  is  recorded  in 
which  this  condition  was  present  and  even  ballotement  could  be  secured  (Fig.  429) . 

28.  Pulsation  of  mass.  No  pulsation  felt,  unless  tumor  lies  over  aorta.  To 
differentiate  between  this  pulsation  and  that  of  aneurysm  of  aorta,  palpate  well 
down  to  the  sides  of  the  mass  to  see  if  there  is  expanding  or  lateral  pulsation. 

29.  Fetal  movements.  None  felt.  In  a  large  smooth  tumor,  suspicious  of 
pregnancy  near  term,  dip  the  hands  in  cold  water  and  then  palpate  the  abdo- 
men, watching  for  fetal  movements. 

30.  Vascular  murmur.     May  or  may  not  be  murmur  in  region  of  large  vessels. 

31.  Fetal  heart  sounds.  None  heard.  Fetal  heart  sounds  are  often  not  heard 
in  full-term  pregnancy,  consequently  not  much  value  attaches  to  their  absence  in 
excluding  pregnancy. 

32.  Fever.     No  fever  unless  there  are  complications  in  the  pelvis  or  elsewhere. 

33.  Emaciation  or  fat  deposition.  There  may  be  either  or  neither.  If  much 
hemorrhage,  usually  anemia  and  some  emaciation. 

34.  Breast  disturbance.  None  ordinarily,  though  occasionally  there  is  some 
tenderness. 

35.  Evidence  of  disease  elsewhere.     None,  unless  complicated. 

The  usual  symptoms  with  the  history  and  general  course  have  already  been 
given. 

In  a  doubtful  case  it  may  be  necessary  to  run  over  the  other  Points  (36  to  63) 
in  the  Diagnostic  Table  (page  288). 

When  making  the  diagnosis  of  fibromyoma  of  the  uterus,  the  following  condi- 
tions and  questions  must  be  considered: 

A.  Other  diseases  presenting  a  mass  or  induration,  which  may  be  mis- 
taken for  a  fibroid.  The  more  common  of  these  diseases  are  salpingitis  v/ith 
exudate,  pelvic  cellulitis,  hydrosalpinx,  pregnancy,  extrauterine  pregnancy,  pel- 
vic tuberculosis,  ovarian  or  parovarian  tumor,  cancer  of  the  uterus. 

B.  Diseases  of  the  uterus  without  a  mass  or  induration,  which  may  be 
mistaken  for  fibroid.  For  example,  retrodisplaced  uterus  with  chronic  endo- 
metritis, chronic  endometritis  with  subinvolution,  carcinoma  of  corpus  uteri, 
tuberculosis  of  uterus,  prolapse  of  uterus,   inversion  of  uterus. 

C.  Fibroid  with  complications.     In  a  case  presenting  anomalous  symptoms,    . 
the   condition    may  be    a  fibroid    complicated    with  pregnancy  or  extrauterine 
pregnancy  or  salpingitis  or  ovarian  tumor  or  broad-ligament  tumor  or  malignant 
disease    of  the  uterus. 

D.  Additional  questions.  After  it  has  been  established  that  a  uterine  fibro- 
myoma is  present,  the  following  points  are  to  be  considered: 

1.  Does  the  fibroid  tumor  cause  all  the  symptoms?     If  not,  what  symptoms 

are  caused  by  it?     What  causes  the  other  symptoms? 

2.  What  is  the  relation  of  the  tumor  or  tumors  to  the  uterine  wall  and  ca^^ity? 

3.  What  is  the  relation  of  the  tumor  or  tumors  to  the  other  pelvic  organs  and 

to  the  pelvic  wall  and  to  the  peritoneum? 

4.  What     complications     are    present — particularly    pregnancy,    malignant 

disease,  pelvic  inflammation,  heart  disease,  kidney  disease? 


PALLIATIVE  TREATMENT  637 

5.  What  has  been  the  progi-ess  of  the  disease  in  this  case,  and  what    will 
probably  be  the  further  progi-ess? 

TREATMENT. 

In  regard  to  treatment  there  are  three  propositions  to  be  considered:  (A)  no 
treatment,  (B)  palliative  treatment  and  (C)  curative  treatment. 

A.  NO  TREATMENT. 

A  certain  small  percentage  of  fibromyomata  are  discovered  by  accident,  i  e., 
during  a  pelvic  examination  for  symptoms  not  due  to  the  fibroid.  The  fibroid  is 
small,  has  caused  no  symptoms,  is  not  likely  to  cause  symptoms  soon,  and  is  not 
likely  to  aggi-avate  the  symptoms  due  to  the  other  trouble. 

Such  a  tumor  requires  no  treatment,  and  it  is  just  as  well,  as  a  rule,  that  the 
patient  be  not  informed  of  its  presence.  She  should,  however,  be  kept  under  ob- 
servation, to  see  if  there  is  any  increase  in  the  gi-owth.  Explain  the  condition  to 
the  husband  or  other  responsible  relative,  that  your  skill  be  not  called  in  ques- 
tion should  the  patient  be  examined  by  some  other  physician  and  the  presence 
of  a  tumor  announced. 

There  is  one  class  of  small  fibroids,  that  I  feel  constitutes  an  exception  to  this 
rule  of  "no  symptoms,  no  treatment,"  namely,  cervix  fibroids.  When  situated 
in  the  lower  part  of  the  uterus,  a  fibroid  of  any  considerable  size  is  a  dangerous 
affair  in  the  child-bearing  period.  If  pregnancy  should  take  place,  the  tumor 
will  probably  increase  in  size  and  may  become  a  serious  menace  to  labor  at  term. 
Again,  a  cervix  fibroid  is  likely  to  cause  symptoms  (bladder,  rectal  or  menstrual) 
at  any  time,  even  though  small.  Such  a  tumor  in  a  married  woman  should  be 
removed.  If  not  complicated  by  tumors  elsewhere  in  the  uterus,  it  may  be 
approached  from  the  vagina  and  removed  by  a  comparatively  simple  operation. 

B.  PALLIATIVE  TREATMENT. 

Palliative  treatment  is  symptomatic.  It  is  directed  towards  relieving  the  dis- 
turbances occasioned  by  the  fibroid  and  making  the  patient  more  comfortable. 
The  principal  disturbances  requiring  the  palliative  treatment  are  the  bleeding 
and  the  pressure  symptoms. 

Measures  for  Palliative  Treatment. 

The  palliative  measures  are  (1)  tonic  measures,  (2)  uterine  astringents,  (3) 
vaginal  packings,  (4)  intrauterine  treatment,  (5)  ligation  of  uterine  arteries,  and 
(6)  removal  of  ovaries  with  ligation  of  ovarian  arteries. 

1.  General  tonic  and  hygienic  measures.  The  better  the  patient's  general  health, 
the  less  the  annoyance  from  the  fibromyoma.  Consequently  there  should  be 
employed  laxatives  (as  in  pelvic  inflammation),  tonic  medicines,  avoidance  of 
long  walks,  rest  at  the  menstrual  periods,  douches  as  indicated  by  discharge,  and 
a  general  regime  to  improve  the  general   health  and    diminish  pelvic  congestion. 

2.  Uterine  astringents.     These  are  hemostatic  remedies,  administered  for  the 


638  FIBROMYOMA  OF  THE  UTERUS 

purpose  of  diminishing  the  bleeding  (menorrhagia  and  metrorrhagia).  The  hem- 
ostatic remedies  thus  used  are  ergotin,  stypticin,  hydrastinin,  adrenalin  (prefer- 
able to  thyroid  extract  or  mammary  extract)  and  calcium  chloride  (see  Formulae). 

Ergotin  is  the  one  that  has  been  most  extensively  used,  It  is  an  exceedingly 
useful  remedy  for  temporarily  lessening  the  memorrhagia.  Continued  for  several 
months  in  one  grain  to  two  grain  doses  it  produces  marked  improvement  in  cer- 
tain cases.  Other  tonics  may  be  combined  mth  the  ergotin  (see  ergotin  and  nux 
vomica  capsule — Formulae)  and  if  there  is  much  pain  it  is  well  to  combine  also  a 
sedative  such  as  cannabis  Indica  (see  Formulae). 

Byford  cites  a  series  of  101  fibroid  cases  treated  by  ergot.  Twenty  were  reported 
cured.  In  39  others  the  tumor  was  reduced  in  size  and  the  symptoms  relieved. 
In  19  others  the  hemorrhage  diminished  but  the  tumor  remained  the  same  size. 
In  21  there  was  no  effect.  Nelson  collected  153  cases  treated  by  ergot,  of  which 
11  died.  Even  in  cases  where  operation  is  necessary,  ergot  (preferably  in  the  form 
of  ergotin)  is  a  useful  palliative  measure  while  the  patient  is  waiting. 

3.  Vaginal  treatment.  Antiseptic  vaginal  douches  are  required  in  cases  present- 
ing leucorrhoea  or  bloody  discharge.  Vaginal  packing  may  be  needed  to  check 
bleeding  temporarily  or  to  raise  an  impacted  tumor  out  of  the  pelvis.  A  firm 
vaginal  packing  of  antiseptic  gauze,  or  of  cotton  (made  antiseptic  by  iodoform  and 
tannic  acid  equal  parts,  dusted  in  freely)  is  an  excellent  measure  for  temporary 
control  of  bleeding  from  within  the  uterus.  The  patient  is  kept  quiet  in  bed  and 
the  packing  changed  every  two  or  three  days  as  necessary  to  prevent  decompo- 
sition. This  may  be  used  in  conjunction  with  uterine  astringents,  to  control  bleed- 
ing temporarily,  while  the  patient  is  being  built  up  for  operation  or  is  being  taken 
to  a  place  for  operation.  When  the  bleeding  can  be  thus  controlled,  the  dangers 
of  intra-uterine  disturbance  (packing,  instrumentation)  are  thus  avoided. 

4.  Intra=uterine  measures.  The  intra-uterine  measures  for  the  control  of  the 
hemorrhage  are  (a)  electricity,  (b)  curetment  and  (c)  applications  and  packing. 

a.  Electricity.  In  certain  cases  of  small  interstitial  or  submucous  gi-owths, 
this  is  a  useful  palliative  measure.  The  details  of  the  application  of  electricity  for 
uterine  bleeding  are  given  in  chapter  iii  (page  356) . 

The  use  of  heavy  currents,  running  up  to  200  and  250  m.  a.  (Apostoli  method), 
with  or  without  puncture,  is  not  advisable.  It  is  too  hazardous  for  the  uncertainty 
of  result.  It  may  cause  serious  necrobiotic  or  inflammatory  changes,  which  add 
very  much  to  the  danger  of  the  subsequent  operation,  and  it  has  even  caused  death. 
It  is  not  to  be  recommended  except  in  urgent  conditions  where  the  patient  can  not 
undergo  operation  for  the  removal  of  the  gi'owth.  Some  still  cling  to  it  as  a  cura- 
tive measure.  Massey,  of  Philadelphia,  in  reporting  86  cases  subjected  to  this 
treatment,  stated  that  64  resulted  in  "  practical  success  "  (symptomatic  cure)  and 
of  these  the  tumor  was  "extruded  through  the  cervix  in  whole  or  in  part  or  in  4, 
disappeared  by  absorption  in  12,  and  was  reduced  in  size  in  3%."  Hirst,  of  Phila- 
delphia, who  was  one  of  a  committee  of  three  appointed  by  the  Philadelphia  County 
Medical  Society  to  investigate  this  treatment,  states  that  "  in  three  years'  time  not 
a  single  case  was  presented  to  us  of  a  tumor  reduced  in  size  by  electrical  treatment.' ' 

Even  the  \ise  of  the  milder  currents,  as  first  mentioned  above,  presents  the  usual 
dangers  of  intra-utorine  instrumentation  and  is,  as  a  rule,  advisable  only  in  non- 


PALLIATUE  TRi:Ar.Mi:NT  ^39 

operable  cases,  or  in  operable  cases  only  to  control  otiierwise  uncontroluble  l^leed- 
ing  until  the  patient  can  be  gotten  in  condition  for  operation. 

b.  CuRET.MENT.  This  may  control  bleeding  temporarily  in  those  cases  in  which 
the  bleeding  is  due  to  hyperplasia  of  the  endometrium.  In  many  cases,  however, 
the  cavity  is  so  distorted  that  the  curet  can  only  wound  parts  of  the  wall  here  and 
there  without  removing  the  entire  endometrium.  In  addition  to  this  uncertainty 
of  controlling  the  hemorrhage,  there  is  danger  of  infection  of  the  uterine  wall  or 
infection  and  necrosis  of  the  gi-owth,  leading  to  an  exceedingly  dangerous  con- 
tlition.  Schroeder  reports  a  case  of  necrosis  of  a  submucous  tumor,  the  capsule  of 
which  had  been  torn  by  the  curet. 

In  carefvdly  selected  cases,  curetment  may  be  advisable,  partially  as  a  diagnos- 
tic measure,  but  there  must  be  a  clear  understanding  of  the  dangers  incident  to  it 
and  good  reason  for  taking  the  risk.  In  the  hands  of  those  experienced  in  the 
selection  of  cases  and  in  the  use  of  the  curet,  the  probability  of  any  serious  com- 
plication from  a  clean  curetment  is  not  great.  But  there  is  gi-eat  risk  in  careless 
intra-uterine  instrumentation  in  these  -cases,  even  the  simple  introduction  of  the 
uterine  sound  (see  Figs.  610,  611). 

c.  Intra-uterixe  applications.  These  are  dangerous  and  inefficient.  In 
inoperalbe  cases  the  judicious  use  of  the  curet  or  of  electricity  is  preferable. 
Occasionally,  as  an  emergency  measure  for  the  immediate  control  of  alarming 
hemorrhage,  intra-uterine  packing  may  be  used.  But  usually  a  firm  vaginal  pack- 
ing \vi\\  secure  the  same  results  without  the  dangers  incident  to  intra-uterine 
instrumentation. 

5.  Ligation  of  the  uterine  arteries  to  diminish  the  blood  supply  to  the 
gi^owth  and  check  bleeding.  There  has  been  considerable  dispute  as  to  who  is 
entitled  to  the  claim  of  priority  in  originating  vaginal  ligation  of  the  uterine 
arteries  for  this  disease.  My  friend.  Dr.  W.  B.  Dorsett,  of  this  city,  suggested  it 
in  1890  in  an  article  entitled  "A  Case  of  Atrophy  of  the  Female  Genitalia  Follow- 
ing Pregnancy,  and  Remarks."  Gottschalk,  in  an  article  published  in  1892, 
remarked  that  ligation  of  the  uterine  arteries  might  be  a  useful  measure  and 
stated  that  he  had  performed  the  operation  in  two  cases.  Franklin  H.  ^lartin 
suggested  vaginal  ligation  of  the  base  of  the  broad  ligaments  in  1893,  and  in 
1894  reported  six  cases  treated  by  this  method.  Several  series  of  cases  have 
since  been  reported.  The  operation  proves  disappointing  in  a  large  proportion 
of  the  cases. 

Since  the  perfection  of  myomectomy  and  hysterectomy,  this  uncertain  method 
is  applicable  only  in  exceptional  cases.  It  is  useful  in  certain  patients  who  are  in 
too  bad  a  condition  for  operation  for  removal  of  the  tumor.  Also,  it  may  be 
tried  in  patients  who  refuse  radical  methods  and  prefer  to  submit  to  the  smaller 
and  less  serious  operation.  Only  interstitial  growths  are  suitable  for  it,  and  the 
operation  should  be  conducted  so  as  to  ligate  practically  all  the  main  vessels  sup- 
plying the  region  of  the  gi-owth.  In  cases  where  the  vessels  in  the  upper  part  of  the 
broad  ligaments    can  be  reached  from  below,  they  also  should  be  ligated. 

6.  Removal  of  the  ovaries,  with  ligation  of  the  ovarian  arteries.  This  opera- 
tion cuts  off  the  blood  supply  through  the  upper  part  of  each  broad  ligament  and 
also  stops  the  recurring  menstrual  congestion.   There  is  frequently  considerable  dif- 


640  FIBROMYOMA  OF  THE  UTERUS 

ficulty  in  reaching  the  adnexa  and  vessels,  because  the  tumor-mass  is  in  the  way  or 
because  of  comphcating  adhesions  from  tubal  inflammation,  so  there  is  more  dan- 
ger attached  to  it  than  one  might  at  first  thought  suppose.  In  a  reported  series 
of  29  cases  there  were  three  deaths.  In  another  reported  series  of  262  cases  the  mor- 
tality was  1.5%. 

Cullingworth  had  25  cases  without  a  death.  He  mentions  also  that  in  three  cases 
in  which  the  operation  was  attempted,  one  or  both  appendages  could  not  be  recog- 
nized and  their  removal  had  to  be  abandoned. 

In  Martin's  65  cases,  menstruation  continued  indefinitely  after  operation  in  a 
considerable  proportion  of  them,  and  in  6%  subsequent  hysterectomy  was  neces- 
sary. This  operation,  also,  is  limited  to  comparatively  small  interstitial  tumors. 
In  these  it  will  diminish  the  hemorrhage  and  reduce  the  size  of  the  growth  in  pro- 
ably  more  than  half.  In  10  to  15  %  of  the  cases,  continued  hemorrhage  or  contin- 
ued growth  of  the  tumor  or  some  serious  degeneration  of  the  same,  necessitates 
later  radical  operation.  As  an  operation  of  choice,  it  is  not  to  be  compared  to 
removal  of  the  gi-owth,  but  as  an  operation  of  necessity,  it  may  do  much  good.  For 
example,  when  the  abdomen  has  been  opened  and  the  tumor  found  of  such  charac- 
ter or  with  such  complications  that  its  removal  is  not  advisable,  or  when  the  patient 
suddenly  passes  into  such  serious  condition  during  operation  that  the  contemplated 
radical  operation  cannot  be  proceded  with,  then  the  ovarian  vessels  and  other 
vessels  within  easy  reach  may  be  quickly  ligated  and  the  ovaries  removed  and  the 
abdomen  closed. 

Of  course,  every  particle  of  ovarian  tissue  must  be  removed  if  the  cessation  of 
menstruation  is  to  be  secured,though  the  simple  ligation  of  the  principal  vessels  sup- 
plying the  tumor  may  make  some  improvement.  The  enlargement  of  the  blood 
vessels  in  the  vicinity  of  the  tumor,  adds  materially  to  the  danger  of  the  opera- 
tion. Fatal  hemorrhage  has  occured  from  the  puncture  of  a  dilated  vessel  by  the 
pedicle  needle. 

Indications  for  palliative  treatment. 

Palliative  treatment  is  required  in  the  following  classes  of  cases: 

1.  When  the  symptoms  are  slight  and  transitory.  In  some  of  these  cases  the 
judicious  employment  of  pallative  measures  No.  1  and  No.  2,  will  relieve  the  pelvic 
disturbance  so  much  that  the  patient  is  symptomatically  a  well  woman. 

2.  When  the  patient  is  not  in  condition  for  operation,  because  of  some  temporary 
trouble.  In  some  cases  the  patient  is  so  anemic  that  to  subject  her  to  a  major  oper- 
ation would  be  a  most  serious  menace,  hence  the  necessity  of  preparatory  treatment. 
It  may  be  necessary  to  employ  palliative  measures  for  several  weeks  before  the  op- 
eration. The  percentage  of  hemoglobin  should  be  brought  up  to  at  least  50%  if 
possible,  and  the- red  blood  corpuscles  to  3,000,000. 

3.  When  the  patient  is  deban-ed  from  operation  by  some  permanent  trouble.  In 
these  cases,  the  palliative  measures  must  be  employed  indefinitely. 

4.  When  the  patient  refuses  operation.  Some  patients  prefer  to  get  along  as 
best  they  can,  rather  than  undergo  a  serious  operation.  In  all  of  these  cases, 
much  relief  can  be  given  by  palliative  measures  judiciously  employed,  and  some 
may  be  kept  in  comparative  comfort  indefinitely. 


CURATIVE  TREATMENT  641 


G.  CURATIVE  TREATMENT. 

The  only  reliable  curative  treatment  for  uterine  fibromyomata  is  removal  by 
operation. 

Operative  measures. 

The  various  operative  measures  looking  to  the  removal  of  the  growth  are  as  fol- 
lows : 

Myomectomy — Removal  of  the  tumor  or  tumors  and  preservation  of   the  uterus. 

Abdominal  Myomectomy — Enucleation  from  the  outer  surface  of  the  uterus. 

Vaginal  Myomectomy — Enucleation  from  the  outer  surface  of  the  uterus  (cer- 
vix) or  from  the  inner  surface  (by  splitting  the  uterus). 

Supravaginal  Hysterectomy — Removal  of  the  tumor  and  of  the  body  of  the  uterus, 
leaving  the  cervix.  This  is,  of  course,  carried  out  through  the  abdomen  and  is 
the  form  of  operation  usually  referred  to  as  "abdominal  hysterectomy  for  fibroid" 
and  "abdominal  hystero-myomectomy." 

Total  Hysterectomy — Removal  of  the  tumor  and  of  the  entire  uterus,  including 
the  cervix.  This  is  carried  out  through  the  abdomen  or  through  the  vagina,  as 
thought  best  in  the  particular  case.  In  certain  exceptional  cases  it  is  preferable 
to  carry  out  the  operation  as  a  combined  vaginal  and  abdominal  hysterectomy. 

Each  of  the  operative  measures  given  above  has  its  advantages  and  disadvan- 
tages in  various  classes  of  cases.  While  there  is  not  space  here  for  a  general  dis- 
cussion of  this  subject,  I  think  it  advisable  to  call  attention  to  certain  precautions 
that  should  be  taken  in  order  to  avoid  cancer  of  the  cervical  stump  after  supra- 
vaginal hysterectomy. 

The  physiological  and  technical  advantages  of  leaving  the  cervix  are  beyond 
question.  The  stubborn  fact,  that  will  not  down  and  that  stands  as  a  spectre  imper- 
atively demanding  a  close  study  of  the  question  is  this:  that  in  a  number  of  cases, 
treated  by  supravaginal  hysterectomy,  the  patient  has  later  died  of  malignant 
disease  of  the  cervix.  It  is  easy  to  say  "  for  that  reason  we  should  remove  the  cer- 
vix in  all  cases."  That  would  be  an  easy  solution  of  the  problem  as  far  as  the 
operator  is  concerned,  but  I  do  not  believe  it  is  the  best  from  the  standpoint  of 
results  to  the  patients.  The  mortality  would  be  higher  and  the  morbidity  would 
be  higher — all  for  the  purpose  of  attaining  a  security  which  I  am  satisfied  can  be 
obtained  in  a  way  that  is  decidedly  safer,  though  somewhat  more  troublesome. 

That  way,  is  to  observe  the  following  precautions  before  and  during  and 
after  operation: 

Before  Operation. 

1.  Examine  carefully  to  exclude  malignant  disease  of  the  cervix  or  corpus  uteri, 
in  suspicious  cases  making  a  microscopic  examination  of  clippings.     If  malignant 


(342  FIBROMYOMA  OF  THE  UTERUS 

disease  is  found,  of  course,  total  hysterectomy  with  wide  removal  of  the  parame- 
trium  is  indicated. 

2.  Ascertain  if  the  cervix  is  severely  lacerated  or  the  seat  of  chronic  irritation 
from  any  cause.     If  so,  employ  total  hysterectomy. 

3.  If  there  has  been  recent  infection  in  the  uterine  cavity  or  adjacent  tissues,  with 
the  development  of  a  condition  making  immediate  operation  necessary,  employ 
total  hysterectomy. 

4.  In  some  cases  total  hysterectomy  is  required  because  of  the  situation  of  the 
tumor. 

In  all  other  cases  requiring  removal  of  the  uterus,  supravaginal  hysterectomy 
is  the  preferable  operation. 

During  Operation. 

5.  As  soon  as  the  tumor  is  removed,  have  a  responsible  assistant  open  it  and 
make  a  rapid  and  critical  examination  of  the  tumor  and  uterus.  If  anything  sug- 
gesting malignant  change  is  found,  remove  the  cervix. 

After  Operation. 

6.  After  operation  submit  all  specimens  to  a  microscopic  examination,  of  suffi- 
cient thoroughness  to  determine  the  presence  or  absence  of  malignant  infiltration. 
If  mahgnant  change  is  found,  promptly  remove  the  cervical  stump.  This  can  be 
readily  removed  per  vaginam. 

By  these  measures,  supravaginal  hysterectomy  is  limited  to  cases  in  which  the 
cervix  is  practically  normal  and  in  which  the  chance  of  development  of  malignant 
disease  is  so  sUght  as  not  to  constitute  a  practical  contra-indication  to  preserva- 
tion of  the  cervix. 

Indications  for  Operation. 

In  what  cases  is  removal  of  the  growth  advisable?  As  a  general  proposition  it 
may  be  stated  that  the  growth  should  be  removed  when  there  are  troublesome 
symptoms  which  persist  after  the  employment  of  palliative  measures  No.  1  and  No. 
2,  or  in  which  the  conditions  are  such  that  those  measures  are  not  likely  to  give 
relief.  In  a  considerable  proportion  of  the  cases  the  symptoms  are  so  severe  and 
threatening  that  there  is  no  question  as  to  the  advisability  and  urgency  of  opera- 
tion for  removal. 

In  the  majority  of  cases,  however,  the  symptoms  are  not  so  severe  nor  threaten 
ing,  and  by  palliative  measures  the  patient  may  be  made  fairly  comfortable  for  a 
time.  In  such  cases  should  the  tumor  be  removed  or  should  it  be  left  alone  until 
serious  symptoms  develop?  This  is  one  of  the  most  important  problems  now  be- 
fore gynecologists  for  solution.  The  facts  so  far  available  indicate  that  in  those 
cases  with  persistent  symptoms,  the  interests  of  the  patient  are  best  conserved  by 
the  removal  of  the  growth  while  the  patient  is  still  in  good  condition  and  the  risk 
accordingly  small.  If  further  experience  confirms  this,  it  will  mark  one  of  the  most 
important  advances  in  surgery — ranking  with  the  establishment  of  the  interval- 
operition  in  appendicitis. 


OIIOICK  OF  TUKATMFA'T  043 

To  present  this  important  su]:)jec-t  cleaily,  I  give  the  following  quotation  from 
a  paper  which  I  read  before  tlie  Missouri  State  Medical  Association  in  May,  1906.* 

"  In  order  to  come  quickly  to  the  point  I  will  eliminate  at  once  those  classes  of 
cases  about  which  there  is  practically  no  question. 

1.  Cases  in  which  the  tumor  causes  no  symptoms.  These  are  seen  by  the  physi- 
cian only  rarely  and  then  usually  by  accident. 

2.  Cases  in  which  the  tumor  is  small  and  is  causing  only  slight  sympt()ms(moder- 
ate  menorrhagia  or  dysmenorrhoea)  which  are  relieved  by  general  tonic  treatment 
with  the  addition  of  uterine  astringents  (ergotin,  stypticin,  hydrastis),  and  tiie 
symptoms  do  not  return  soon  after  the  treatment  has  been  discontinued. 

3.  Cases  in  which  the  patient  is  past  45  years  of  age  and  the  tumor  is 
stationary  in  size,  not  large  enough  to  cause  disturbing  pressure  symptoms, 
accompanied  by  only  moderate  menorrhagia  and  without  troublesome  inter- 
menstrual symptoms. 

"  It  will  hardly  be  questioned  that  for  these  three  classes  the  expectant  plan  is 
the  preferable  treatment. 

4.  Cases  presenting  conditions  that  threaten  life  or  cause  persistent  severe  suf- 
fering.    The  necessity  of  operation  in  this  class  has  long  been  generally  recognized. 

"  It  is  the  cases  which  lie  between  these  two  extremes  to  which  I  wish  to  direct 
your  attention.  What  is  the  best  treatment  for  the  patients  who  have  no  threaten- 
ing symptoms?  They  come  for  advice  and  treatment  and  the  question  is,  what  is 
best  to  do  for  them? 

"The  tumor  is  of  moderate  size,  perhaps  as  large  as  the  fist  or  two  or  three  times 
as  large.  The  patient  is  fairly  well  nourished,  probably  somewhat  anemic,  but  not 
seriously  so.  The  menstrual  flow  is  excessive  but  by  the  continuous  administration 
of  ergotin  or  stypticin  it  can  be  held  down  to  very  moderate  menorrhagia.  The 
backache  and  pelvic  pressure  are  very  troublesome  at  the  menstrual  periods  but 
between  periods  the  patient  feels  fairly  well  and  is  able  to  do  her  work  and  attend 
to  her  social  duties.  She  feels  dragged  out  a  good  part  of  the  time  and  has  back- 
ache and  pelvic  discomfort  after  extra  exertion.  The  patient  is  a  semi-invalid — • 
not  sick  enough  to  be  called  sick  and  not  well  enough  to  be  called  well. 

"She  is  between  30  and  40  years  of  age  and  has  been  under  treatment,  including 
a  general  tonic  regime  with  the  addition  of  uterine  astringents,  long  enough  to  make 
it  plain  that  the  condition  described  is  the  best  that  can  be  obtained  short  of 
operation. 

"What  advice  shall  we  give  such  a  patient?  Should  the  tumor  be  let  alone  or 
should  it  be  removed? 

"It  is  easy  to  say  to  the  patient:  'Wait.  There  is  no  special  indication  for 
operation  just  now,  there  may  be  no  serious  increase  in  the  symptoms  at  any  time, 
and  it  is  possible  that  after  the  menopause  the  troublesome  symptoms  will  largely 
disappear.' 

"  The  points  made  in  that  advice  are  all  literally  true  and  the  advice  itself 
seems    plausible.       But   when    some    complication    that  would   have    been  pre- 

*  Some  Questions  Concerning  the  Treatment  of  Uterine  Fibromyomata,  by  H.  S.  Crosseu, 
M.  D.     Journal  of  Missouri  State  Medical  Association,  Vol.  Ill,  No.  3,  1906. 


644  FIBROMYOMA  OF  THE  UTERUS 

vented  by  early  removal  of  the  tumor,  rapidly  causes  the  death  of  our  patient  or 
forces  her  to  operation  with  quadrupled  risk,  we  begin  to  doubt  the  wisdom  of  the 
waiting  advice.  This  is  not  a  picture  of  fancy.  Nearly  all  the  fibromyoma  cases 
that  were  operated  on  the  world  over  previous  to  the  last  two  or  three  years, 
and  the  larger  part  of  those  that  are  operated  on  today,  have  passed  through 
the  process  just  mentioned. 

"  The  patient  went  to  a  physician  who  treated  her  expectantly,  according  to  the 
established  usage,  and  congi-atulated  himself  that  she  was  getting  along  pretty  well. 
And  she  was  "getting  along  pretty  well" — "pretty  well"  toward  a  condition  that 
greatly  increased  the  risk  of  the  operation  which  was  finally  necessary. 

"I  may  speak  plainly  for  I  speak  from  experience.  The  cap  fits  and  I  put  it  on — 
I  trust  others  will  do  the  same. 

"In  many  cases  the  physician  who  long  treated  the  patient  loses  the  lesson  of  the 
case  through  no  fault  of  his  own.  Some  of  these  patients  pass  through  many  hands 
in  the  various  stages  of  the  tumor's  growth,  for  it  extends  through  many  years.  Per- 
haps half  a  dozen  physicians  have,  from  the  same  case,  been  established  in  their 
conclusion  that  fibroid  patients  get  along  very  well  and  rarely  need  operation,  while 
only  the  last  physician  whom  the  patient  consults  has  the  true  lesson  of  the  case 
forced  upon  him  in  a  way  that  cannot  be  misunderstood.  In  some  cases  the  ser- 
ious condition  advances  so  rapidly  or  so  insidiously  that  the  patient  dies  without 
the  consideration  of  operative  measures,  or  is  found  in  such  condition  that  opera- 
tion is  no  longer  possible. 

"Some  physicians  find  it  hard  to  believe  that  uterine  fibroids  really  cause  death 
except  so  rarely  that  the  cases  may  be  classed  as  curiosities.     A  practical  experi- 
ence with  even  a    moderate  number    of    advanced  cases  will  quickly  dispel    this 
illusion,  provided  the  physician  watches  the  cases  to  their  terminations.     Bishop 
reports  27  deaths  due  to  fibroids  without  operation. 

"  On  the  other  hand,  in  deciding  what  to  do  for  these  patients,  it  is  easy  to  take 
the  other  short-cut  and  advise  all  patients  with  palpable  fibroids  to  be  operated 
on — that  is,  it  is  easy  for  the  physician.  But  before  advising  operation  in  any 
case  we  must  assure  ourselves  that  the  chance  of  death  assumed  is  fully  justified 
by  the  danger  of  delay  in  that  particular  case.  Then,  if  death  comes  in  spite  of 
every  precaution,  we  know  at  least  that  it  was  not  an  unwarranted  sacrifice. 
It  is  easy  enough  to  advise  operation,  but  it  is  not  so  easy  to  restore  life  to  the 
deceased — who,  but  for  the  operation,  might  have  lived  in  comparative  comfort 
to  old  age. 

"But  what  advice  shall  we  give  our  patient?  The  symptoms  at  present  are 
not  such,  in  themselves,  as  to  necessitate  operation.  They  are  not  threatening 
speedy  death,  neither  are  they  causing  great  disability.  If  they  continue  as  they 
are,  the  patient,  by  continuing  under  treatment,  by  lying  down  most  of  the  men- 
strual days  and  by  being  careful  at  other  times  as  to  extra  work  and  walking, 
may  live  a  fairly  comfortable  life. 

"Many  women,  probably  most  women  in  ordinary  circumstances,  would  prefer 
this  state  rather  than  seek  complete  health  through  a  dangerous  operation,  even 
though  the  operative  mortality  is  small.  And  I  am  not  going  to  condemn  such  a 
choice — in  fact,  granted  the  stationary  character  of  the  trouble,  I  would  strongly 
advise  such  a  course. 


CHOICE  OF  TREATMENT  645 

"But  have  we  any  well-grounded  assurance  that  the  trouble  will  remain  station- 
ary?   There  lies  the  gist  of  the  matter. 

"The  patient  comes  to  the  physician  to  learn,  not  what  she  already  knows,  viz., 
that  with  the  present  symptoms  she  can  get  along  in  comparative  comfort,  but 
she  comes  to  learn  whether  or  not  it  is  safe  for  her  to  go  along  in  that  way.  She 
wants  to  know  whether  she  had  better  have  the  tumor  removed  now,  while  she  is 
in  good  condition  and  the  risk  accordingly  small,  or  whether  she  had  better  wait 
and  see  whether  or  not  severe  symptoms  develop. 

"This  brings  us  up  squarely  to  the  question  of  prognosis  in  this  class  of  myoma 
cases. 

"It  is  interesting,  and  pertinent  to  the  subject,  to  notice  for  a  moment  the 
method  of  development  of  surgical  treatment  in  general  and  of  abdomino-pelvic 
surgery  in  particular. 

"At  first  major  surgery  was  invoked  in  only  the  most  desperate  cases,  those  that 
were  passing  to  certain  and  speedy  death.  This  was  proper  for,  in  the  state  of  ex- 
perience at  that  time,  the  operation  itself  meant  death  in  many  cases.  It  was  a 
desperate  remedy  for  a  desperate  condition,  and  occasionally  attained  success.  As 
the  technique  was  perfected,  more  of  the  desperate  cases  were  rescued  from  death. 
As  these  fatal  conditions  for  which  operation  was  carried  out,  were  studied  in  con- 
junction with  the  experience  gained  in  the  operative  work,  physicians  began  to 
anticipate  the  desperate  and  terminal  conditions,  and  to  operate  when  the  pa- 
tient was  in  a  somewhat  better  condition — and  with  much  better  success. 

"'Then  they  began  to  look  still  further  ahead  and  consider  the  possibilities  of  sur- 
gery in  conditions  that  became  inoperable  many  months  before  death.  Thus 
was  gradually  worked  the  prognosis  and  required  treatment  for  ovarian  tumors, 
for  uterine  cancer  and  for  other  pelvic  and  abdominal  diseases  that  were  found  to 
prove  invariably  fatal  within  a  few  years.  The  necessity  of  early  operation  in 
these  conditions  that  proved  fatal  in  a  comparatively  short  time,  was  soon  estab- 
lished, and  gained  general  acceptance  long  ago.  The  course  of  such  diseases  was 
quickly  run.  Within  the  short  period  of  a  few  years,  the  physician  saw  the  pa- 
tient a  well  woman,  then  the  disease  beginning,  then  its  full  development  and 
then  the  invariable  death,  this  series  of  events  taking  place  so  quickly  that  it  was 
all  under  the  one  physician  and  within  his  recent  recollection.  The  lesson  was 
obvious — delay  meant  death. 

"That  field  conquered,  surgical  attention  was  directed  to  the  question  of  early 
operation  in  those  diseases  which,  though  not  invariably  causing  death,  never- 
theless frequently  caused  death  and  in  another  large  proportion  of  the  cases  caused 
persistent  suffering  and  invalidism.  Then  was  worked  out  the  advisability  of 
operation  in  the  quiescent  period  (before  the  onset  of  the  threatening  or  terminal 
symptoms)  in  cases  of  persistent  salpingitis,  appendicitis,  nephrolithiasis,  chole- 
lithiasis, and  many  other  abdominal  and  pelvic  conditions  that  run  a  comparatively 
rapid  course.  In  the  case  of  a  patient  with  one  of  the  diseases,  the  prognosis  is 
not  necessarily  fatal.  Many  such  patients  having  persistent  symptoms  have 
lived  to  old  age.  And  yet  when  any  one  of  these  conditions  is  unmistakably  pres- 
ent, and  there  are  persistent  symptoms  from  it,  there  is  little  question  l^ut  that  re- 
moval of  the  disease  is  the  part  of  wisdom,  not  so  much  because  the  present  symp- 


646  FIBROMYOMA  OF  THE  UTERUS 

toms  are  troublesome  but  because  the  symptoms  indicate  that  the  process  is  con- 
tinuing active — it  having  been  established,  and  generally  accepted,  that  when  any 
one  of  these  diseases  is  persistently  active,  it  is  liable  at  any  time  to  develop  a  con- 
dition that  may  cause  the  patient's  death  or  make  more  hazardous  the  operation 
then  necessary  to  save  her  from  death. 

"This  is  exactly  the  condition  that  is  present  in  uterine  fibromyoma  with  persist- 
ent symptoms,  even  though  the  symptoms  are  not  for  the  present  threatening  or 
disabling.  Yet  this  fact  is  not  generally  recognized,  and  there  is  good  reason  for 
its  not  being  recognized.  Physicians  generally  have  the  excellent  habit  of  requir- 
ing proof  before  accepting  a  statement,  and  the  absolute  proof  as  to  the  advisa- 
bility of  early  operation  in  uterine  fibromyoma  has  not  been  forthcoming.  I  say 
this  with  all  due  respect  to  the  many  excellent  men  who  have  expressed  as  many 
excellent  variations  of  the  opinion  that  early  operation  is  advisable.  Opinion  is 
not  proof.  It  usually  precedes  proof  and  stirs  up  and  brings  out  proof.  When 
the  proof  is  produced,  however,  it  is  sometimes  found  that  the  opinion  which  pre- 
ceded it,  proceeded  in  the  wi-ong  direction.  So  I  am  not  surprised  that  the  profes- 
sion waits  to  see  the  proof,  before  accepting  the  statement  that  early  operation 
should  be  the  rule  in  these  cases. 

"When  we  come  to  produce  the  proof  we  find  that  we  haven't  it — at  least,  if  any 
one  has  it  I  have  not  seen  it,  and  I  have  spent  a  good  deal  of  time  looking  for  it  in 
the  last  few  years. 

"Facts  are  gradually  being  accumulated,  and  many  bearing  on  various  phases 
of  the  subject  have  already  been  presented  to  the  profession,  but  the  actual  life- 
history  of  fibromyoma  patients,  of  the  class  under  consideration,  has  not  been 
followed  up  and  completely  recorded  in  a  sufficient  number  of  cases  to  enable  us 
to  present  positive  proof  as  to  what  proportion  of  them  die  of  the  disease,  what 
proportion  suffer  chronic  invalidism,  and  what  proportion  experience  no  serious 
trouble. 

"The  finding  of  fatal  complications  in  a  large  proportion  of  the  operated  cases. is 
not  proof  positive  that  the  less  severe  cases  should  be  subjected  to  operation,  any 
more  than  the  finding  of  perforation  or  abscess  formation  in  a  large  proportion  of 
the  severe  operated  cases  of  appendicitis  was  proof  positive  that  it  was  wise  to  sub- 
ject the  less  severe  cases  to  operation. 

"The  principal  question  concerning  these  fatal  complications  is  not  'What  pro- 
portion of  operated  cases  present  them?'  but  'What  proportion  of  the  mild  cases 
progress  to  them?' 

"I  do  not  minimize  the  importance  of  tlie  arduous  work  of  determining  accurately 
the  number  of  these  complications  in  operated  cases.  That  is  needed  and  is  neces- 
sary to  the  determination  of  the  proportion  of  serious  results  in  nil  clincial  fibroid 
cases. 

"But  in  our  (nithusi;isni  over  the  ;i(U',oini)lishinent  of  tlu^  fh'st,  we  must  not  mistake 
it  for  the  second.  The  proportion  of  operated  cases  presenting  these  fatal  and 
disabling  complications  is  now  a  matter  of  record,  and  the  record  includes  a  suf- 
ficiently large  number  of  cases  to  justify  fairly  definite  conclusions  on  that  point. 
The  proportion  of  mild  cases  that  progress  to  the  serious  condition  is  not  a  mat- 
ter of  record,  in  fact,  has  not  been  even  approxi-mately  determined,  and  cannot  be 


CHOICE  OF  TREATMENT  647 

until  the  life-histoi'y  nf  n  very  large  series  of  the  vai-ious  classes  of  fibromyoma 
cases,  is  available  for  analysis. 

"This  can  l^e  secured  only  by  following  the  patients  of  each  class  through  many 
years  to  the  end.  No  doubt  this  matter  Has  been  taken  up  to  some  extent  and  will 
be  taken  up  very  generally  and  prosecuted  till  a  sufficiently  large  series  has  been 
secured.  I  hope  to  accumulate  some  information  on  this  point,  at  least  for  mv 
own  satisfaction;  l)ut  it  is  uphill  work.  The  patients  move  and  are  lost  sight  of. 
There  is  not  the  same  mutual  interest  that  attaches  in  operated  cases,  and  the 
patients  are  followed  with  gi-eater  difficulty  and  fewer  returns.  But  this  life- 
history  of  the  less  severe  cases  can  be  obtained  in  time  and  must  be  obtained,  for 
it  is  necessary  to  complete  knowledge  of  the  subject. 

"Some  of  us  have  had  an  experience  in  these  cases  sufficiently  large  to  justify  us  in 
forming  and  expressing  an  opinion  to  assist  in  the  guidance  of  others.  And  though 
we  may  believe  that  our  views  are  sound  and  founded  on  the  facts  as  far  as  they  go, 
and  will  become  more  generally  recognized  as  more  and  more  facts  are  established, 
yet  we  must  not  forget  that  the  complete  proofs,  in  black  and  white,  are  lacking 
at  the  present  time. 

"Why  is  it  so  hard  to  establish  certainly  the  exact  proportion  of  fibromyoma  cases 
that  turn  out  badly?  Because  of  the  slow  progress  and  long  duration  of  the  disease. 
In  persistent  salpingitis  or  appendicitis  the  cases  that  are  going  to  turn  out  badly 
usually  do  so  within  one  or  two  or  three  years,  so  by  watching  a  large  series  of 
cases  for  that  length  of  time  it  could  be  determined  what  proportion  resulted  seri- 
ously, and  could  be  established  by  statistical  proof  just  what  proportion  of  cases 
could  be  saved  from  death  or  disablement  by  early  operation.  The  fibromyoma 
cases,  on  the  other  hand,  present  a  much  more  difficult  problem.  Here  the  al^sence 
of  threatening  symptoms  for  five  or  ten  or  twenty  years,  gives  no  assurance  that 
serious  trouble  may  not  develop  at  any  time.  Case  histories  are  numerous  showing 
that  patients  have  waited  patiently  and  hopefully  for  ten  or  twenty  years,  with 
fibroids  that  produced  no  serious  symptoms,  only  to  come  at  last  to  the  operating 
table  because  of  some  rapidly  developing  trouble  dependent  on  the  tumor.  Con- 
sequently each  patient  must  be  followed  to  the  end  before  we  can  say  that  there 
was  no  occasion  for  removal  of  the  growth  in  that  case. 

"But  we  cannot  wait  until  all  these  things  are  determined  before  giving  our 
patient  advice. 

"  What  are  the  facts  so  far  established,  that  Avill  help  to  guide  us  in  ach'ising 
this  patient? 

"1.  Some  fibromyomata  never  give  serious  trouble.  I  refer  of  course  to  clinical 
fibromj'omata,  i.  e.,  tumors  that  were  recognized  during  life  or  that  could  have 
been  recognized  had  the  patient  come  for  examination.  The  small  latent  fibroid 
nodules,  found  in  such  a  large  proportion  of  sectioned  uteri  removed  post-mortem, 
are  not  now  under  consideration. 

"A  patient  may  go  through  a  long  and  useful  and  happy  life  with  a  palpable 
fibroid,  and  experience  no  particular  difficulty  from  the  growth.  This  fact  has  been 
demonstrated  over  and  over  again  in  clinical  work  and  in  autopsies  on  patients 
who  have  died  of  independent  diseases  or  of  senility. 

"What  proportion  of  cases  run  this  course  we  do  not  know  either  exactly  or  ap- 


648  FIBROMYOMA  OF  THE  UTERUS 

proximately.  We  know  only  that  "some" — a  considerable  number — have  done 
so.  This  fact,  however,  is  sufficient  to  overthrow  the  contention  that  "all 
palpable  fibroids  should  be  subjected  to  operation."  There  is  a  mortality  due  to 
the  operation.  To  be  sure  the  mortality  is  small,  under  proper  technique  and 
surroundings,  and  will  become  much  smaller  as  the  cases  are  subjected  to  opera- 
tion earlier  and  therefore  under  safer  conditions.  But  even  in  the  most  favorable 
cases  there  is,  and  will  continue  to  be,  an  occasional  death  from  the  operation. 
And  before  advising  operation  in  any  case  we  should,  as  already  remarked,  assure 
ourselves  that  the  chance  of  death  assumed  is  fully  justified  by  the  danger  of 
delay  in  that  particular  case. 

"2.  In  a  certain  proportion  of  cases  there  have  developed  fatal  complications, 
which  were  due  to  the  tumor  or  would  have  been  prevented  by  its  early  removal. 

"Just  what  proportion  of  all  clinical  fibroid  cases  have  developed,  or  will  develop, 
these  fatal  complications  we  do  not  know,  and  cannot  know  in  the  present  state  of 
knowledge. 

"Just  what  proportion  of  operated  fibroid  cases  have  developed  these  com- 
plications has  been  determined  in  several  series  of  cases,  through  the  careful  ob- 
servation and  painstaking  labor  of  the  physicians  under  whose  care  the  patients 
came.  No  one  can  investigate  this  subject  mthout  coming  to  feel  under  personal 
obligation  to  the  men  who  have  taken  the  time  and  the  labor  to  prosecute  this 
work  in  a  reliable  way  and  to  place  the  results  before  the  profession.  To  Dr.  Chas. 
P.  Noble,  of  Philadelphia,  belongs  the  credit  of  stirring  up  the  profession  on  this 
subject,  by  presenting  and  keeping  before  it  incontestible  evidence,  from  his  own 
work  and  the  work  of  others,  of  the  great  frequency  of  fatal  and  disabling  compli- 
cations, due  directly  to  these  tumors  or  associated  with  them. 

"In  a  series  of  1,188  cases  collected  by  Noble  (Noble  278,Scharlieb  100,  McDonald 
280,  Martin  205,  Cullingworth  100,  Frederick  215,  Hunner  100),  there  were  found 
the  striking  number  of  795  complications. 

"However,  in  looking  over  this  list  it  is  seen  that  many  of  the  complications  are 
not  serious  and,  of  even  the  serious  ones,  some  are  in  no  way  dependent  on  the 
presence  of  the  tumor. 

"In  order  to  determine  approximately  what  probable  fatalities,  here  noted,  could 
have  been  prevented  by  early  removal  of  the  growth,  I  prepared  the  tabular  anal- 
ysis given  below. 

"The  number  of  tubal  and  ovarian  complications  prevented  by  early  removal  of  the  growth 
depends,  of  course,  on  the  number  of  tubes  and  ovaries  removed.  I  made  the  estimate  on  the 
basis  of  two-thirds  of  the  tubes  removed  (hysterectomy  in  two-thirds  of  the  cases  and  myo- 
mectomy in  one-third)  and  half  of  the  ovaries  removed  (both  ovaries  removed  in  one-third  of  the 
cases  and  one  ovary  removed  in  another  third).  Of  course,  if  found  advisable  to  limit  myomec- 
tomy to  a  smaller  proportion  of  the  cases,  more  tubes  would  be  removed  and  hence  more  tubal 
complications  prevented. 

"As  to  whether  myomectomy  is  preferable  to  hysterectomy  in  a  considerable  proportion  of 
the  cases,  that  is  a  question  concerning  which  there  is  much  of  interest  to  be  said  on  both  sides 
and  it  can  not  be  taken  up  here.  However,  there  is  no  question  but  that,  as  early  operation  is 
more  widely  adopted,  a  larger  proportion  of  the  cases  will  be  found  suitable  for  myomectomy. 
In  fact,  the  more  frequent  saving  of  the  uterus  is  one  of  the  benefits  that  will  follow  the  adop- 
tion of  early  operation  in  these  cases.    The  chance  of  later  enlargement  of  small  "  latent  "  fibroid 


CHOICE  OF  TREATMENT 


649 


nodules  to  the  dignity  of  clinical  fibroids,  is  not  so  great  as  to  deter  us  in  preserving  the  uterus 
in  suitable  cases.  Such  growth  takes  place  occasionally.  Some  months  ago  I  was  obliged  to 
remove  the  uterus  for  extensive  multi-nodular  intra-ligamentary  fibroid  development  in  a 
patient,  aged  31,  who  eighteen  months  previously  had  undergone  myomectomy  in  a  New  York 
hospital.  In  this  particular  case  I  attribute  the  rapid  growth  of  the  fibroids  partly  to  the  chronic 
congestion  of  a  severe  pelvic  inflammation,  resulting  in  pyosalpinx,  the  infection  evidently 
ha^^ng  been  contracted  some  time  after  the  first  operation.  Ordinarily,  according  to  the 
reported  cases  that  have  so  far  come  to  my  notice,  this  development  of  other  tumors  after 
operation  has  not  taken  place  often  enough  to  constitute  a  serious  objection  to  myomectomy 
in  suitable  cases.  Again,  in  certain  cases,  the  preservation  of  the  uterus  is  well  worth  the  risk 
of  a  second  or  even  a  third  operation. 

"In  estimating  the  number  of  serious  tubal  and  ovarian  complications  prevented  by  early 
removal  of  the  tumor,  the  bare  proportion  of  tubes  and  ovaries  removed  does  not  fully  represent 
the  proportion  of  complications  prevented,  for  only  apparently  normal  adnexa  are  left.  Those 
tubes  and  ovaries  w  hich  would  show  serious  trouble  later,  are  likely  to  show  some  abnormality 
at  the  time  of  operation  and  hence  would  be  removed. 

"The  table  includes  1,815  cases,  consisting  of  nine  series  of  consecutive  cases  (Noble  1,118,  as 
mentioned  above,  Watt-Keen  (from  Hofmeier's  clinic)  417,  Webster  210).  The  question  is: 
'What  probable  fatalities,  from  degeneration  of  the  tumor  or  from  local  complications,  would 
have  been  prevented  by  early  removal  of  the  tumor?,'  and  only  the  complications  bearing  on 
this  question  are  mentioned.  In  the  first  column  (A)  is  given  the  number  found  of  the  particu- 
lar degeneration  mentioned.  In  the  second  colum  (B)  is  given  the  number  of  these  that  would 
almost  certainly  have  been  prevented  by  the  early  removal  of  the  tumor.  And  in  the  third 
column  (C)  is  given  the  probable  fatalities  from  the  latter. 

"Number  of  cases,  1815.  ABC 

Necrosis  of  tumor 86 

Suppurating  tumor 10 

Oedematous  tumor 11 

Myxomatous  degeneration  of  tumor 56 

Cystic  degeneration  of  tumor 53 

Calcareous  degeneration  of  tumor.. 36 

Serious  intra-lig.  development  of  tumor 44 

Malignant  disease  of  tumor  or  of  corpus  uteri 65 

Large  hydronephrosis  from  tumor  pressure 6 

T^^^sted  pedicle  of  tumor 33 

Pyosalpinx 37 

Salpingitis 127 

Abscess  of  ovary 10 

Carcinoma  of  ovary 3 

Ovarian  (cyst)  including  dermoids 118 

Probable  Fatalities 345 

"This  shows  probable  fatalities  numbering  345,  or  19  per  cent,  simply  from  the 
tumor  degenerations  and  local  complications  mentioned,  exclusive  of  other  fatal 
and  disabling  effects  of  the  fibroid.  This  I  consider  an  ultra-conservative  estmate. 
I  believe  that,  were  these  cases  traced  to  the  end  without  operation,  the  number 
of  deaths  simply  from  the  conditions  specified  would  considerably  exceed  the  num- 
ber here  estimated. 


86 

80 

10 

8 

11 

4 

56 

40 

53 

30 

36 

6 

44 

15 

65 

65 

6 

3 

3 

2 

24 

15 

84 

12 

5 

3 

2 

2 

75 

60 

650  FIBROMYOMA  OF  THE  UTERUS 

''In  a  recent  report  by  Winter  of  753  operated  cases,  malignant  disease  of  the 
tumor  or  corpus  uteri  was  found  in  39  cases  and  total  necrosis  of  the  tumor  in  17 
cases.  Thus,  counting  only  two  of  the  serious  concUtions  mentioned  in  the  table, 
it  is  found  that  they  include  nearly  8  per  cent  of  his  cases. 

[In  an  article  by  Noble  since  published,  in  which  he  analyzed  a  series  of  2,274 
cases,  it  was  estimated  that  23  per  cent  of  the  patients  would  have  died,  from 
degenerations  or  complications  existing  in  the  uterus  or  in  the  appendages  or  in  the 
abdomen.  In  Ms  study  of  a  series  of  4,480  cases  in  respect  to  carcinoma,  he 
found  carcinoma  was  present  in  2.8%  (in  corpus  uteri  1.5%,  in  cer\ix  1.29%). 
In  a  careful  examination  of  his  own  337  consecutive  cases,  however,  he  found 
carcinoma  in  4%.  As  to  sarcoma,  Winter,  in  500  cases  in  which  grossly  suspicious 
areas  only  were  examined  microscopically,  found  sarcoma  in  3.2%,  but  in  253 
cases  sectioned  systematically,  sarcoma  was  found  in  4.3%.  It  is  probable  then, 
that  if  all  tumors  operated  on  late  were  subjected  to  systematic  microscopic 
examination,  malignant  cUsease  (sarcoma  or  carcinoma)  would  be  found  in  8%.] 

"3.  In  a  certain  proportion  of  cases,  serious  ^dsceral  degenerations  appear  in  dis- 
tant organs.  The  frequent  association  of  heart  disturbance  with  advanced  uterine 
fibroid,  has  attracted  much  attention.  The  proportion  of  cases  showing  heart 
disturbance  is  striking.  Winter  had  266  consecutive  cases  examined  for  heart 
diseases  and  found  heart  disturbance  in  forty  per  cent.  In  five  series  carefully 
examined  (Winter  266,  Strassmann  and  Lehmann  71,  Boldt  79,  Fleck  325,  Web- 
ster 210),  the  number  showing  heart  disturbance  varied  from  25  to  47  per  cent., 
averaging  38  per  cent,  for  the  whole  951  cases.  Of  course,  a  certain  number 
of  these  heart  disturbances  would  have  been  found  in  any  series  of  patients.  But 
making  due  allowance  for  these  the  number  is  too  marked  and  constant  to  be  a 
mere  coincidence.  The  exact  connection  between  the  two  has  not  been  v*^orked 
out.  But  whether  the  heart  disturbances  are  due  principal^  to  the  chronic  anemia 
from  hemorrhage  or  to  the  direct  action  of  some  toxin  manufactured  in  the  fibroid, 
or  constitute  simply  an  associated  product  of  the  same  conditions  that  produced 
the  fibroid — whatever  the  cause — the  fact  remains  that  they  are  there  and  must 
be  reckoned  with.  Some  of  these  are  minor  functional  disturbances  but  on  the 
other  hand  many  are  of  serious  import. 

"That  such  is  the  case  is  sho\Mi  by  Baldy  from  the  records  of  the  Gynecian 
Hospital.  In  the  series  of  3,413  operations,  sudden  post-operative  death  due 
to  circulatory  disturbance  occurred  16  times.  Thirteen  of  these  sudden  deaths 
occurred  in  the  366  fibromyoma  cases,  while  the  3,047  other  operative  cases 
furnished  only  3  such  deaths.  It  occurred  36  times  as  frequently  in  the 
fibroid  ca-ses  a>s  in  the  general  run  of  operative  cases. 

"Other  visceral  degenerations,  from  the  chronic  anemia,  from  pressure  on  the 
ureters  and  from  other,  ejects  of  the  fibroid,  produce  fatalities  due  really  to  the 
fibroid,  but  attributed  to  other  cases. 

"Let  us  now  look  at  some  of  the  facts  that  arc  put  forward  against  tlic  idea  tluil 
myoma  causes  death  in  any  considerable  proportion  of  the  cases. 

"1.  General  mortuary  records  show  only  an  insignificant  death  rate  i:om  this 
disea-se. 


CHOICE  OF  TREATMENT  651 

"The  U.  S.  Census  (1900)  shows  657  deaths  from  fibroid  tumor  of  the  uterus  in 
a  population  of  about  37,000,000  females. 

"The  Great  Britain  Census  (1901)  shows  339  deaths  from  fibroid  tumor  of  the 
uterus  in  a  population  of  about  17,000,000  females.  There  is  a  striking  agi-eement 
here,  both  indicating  that  the  death  rate  is  about  1  in  50,000 — a  very  soothing 
proposition  to  one  called  to  treat  a  patient  so  afflicted.  But  was  this  all  the  deaths 
from  fibroid  disease  in  that  time?  Do  not  the  numl^ers  here  given  represent 
simply  the  cases  in  which  nothing  else  could  be  found  to  account  for  the  death. 
How  about  the  fibromyoma  patients  that  died  of  kidney  disease,  of  heart  disease, 
of  anemia,  of  "uterine  hemorrhage,"  of  uterine  "cancer"  (cancer  of  the  endo- 
metrium associated  with  fibroid  or  a  sloughing  fibroid  mistaken  for  cancer),  of 
salpingitis,  of  peritonitis,  and  of  other  conditions  due  directly  to  the  fibroid  of 
that  would  have  been  prevented  by  its  early  removal?  Until  we  count  the  deaths 
due  to  these  complications,  the  census  figures  amount  to  very  little  as  showing 
the  deaths  due  to  fibroid  disease.  The}^  show  simply  that,  in  the  countries  men- 
tioned, few  patients  die  of  uncomiilicated  fibroids. 

"2.  Hospital  records  of  fibroid  cases  show  few  deaths  among  them.  In  St.  Bar- 
tholomew's Hospital,  among  547  uterine  fibromyoma  cases  there  were  but  29 
deaths,  and  28  of  these  followed  operation.  Here  is  a  series  of  547  fibroid  cases 
only  one  of  which  died  of  the  fibroid  while  28  died  of  the  operation — accurate 
records,  careful   diagnosis,  thoroughly  reliable  report.  What  shall  be  said  to  that? 

"Before  deciding  as  to  the  practical  significance  of  these  figures  I  would  seek 
some  additional  information.  How  many  of  the  28  patients  who  died  following 
operation,  would  have  died  without  operation?  How  many  of  the  547  patients 
with  fibroid  tumors  were  saved  from  death  by  operation?  What  was  the  after- 
history  of  each  one  of  the  non-operated  cases?  When  this  additional  information 
is  obtained,  then  we  will  have  some  idea  as  to  how  many  deaths  from  fibroid 
would  have  occurred  without  operation  in  this  series  of  547  cases. 

"Practicall}^  the  same  deficiencies  appear  in  all  hospital  series  of  fibromyoma 
cases,  and  in  a  measure  necessarily  so,  for  hospital  records  can  not  show  the 
number  of  non-operated  cases  that  come  to  death  or  operation  after  they  leave 
the  hospital. 

"3.  Large  series  of  cases  from  private  records  show  only  a  small  proportion  of 
the  patients  in  realh'  serious  condition.  There  are  many  such  reports.  A  recent 
one  is  that  of  Dr.  E.  J.  Ill,  of  Buffalo,  in  which  he  reports  all  fibroid  cases  seen  by 
him  in  the  preceding  three  years.  There  were  300  cases.  He  operated  on 
53  and  advised  operation  in  6  others,  making  59  cases  in  which  operation  was 
required  according  to  the  indications  that  he  followed.  So  we  have  here  a 
large  series  of  fibromyoma  cases,  carefully  observed  and  reported,  and  in  only 
about  18  per  cent  was  'life  endangered'  or  'health  so  impaired  that  life  was  a 
burden.'  Eighteen  per  cent  of  serious  terminations  is  not  a  small  per  cent  for 
what  some  are  pleased  to  style  a  ' harmless'  gi-owth. '  But  is  that  the  total  number 
of  serious  terminations  in  the  whole  300  cases?  How  many  of  the  patients  who 
v/ere  in  good  conditions  when  he  last  saw  them  will  pro.gress  to  the  same  stage  of 
the  disease  in  which  he  saw  the  18  per  cent? 

"Fibromvoma  of  the  uterus  is  a  very  slow  growing  tumor.     It  may  gradually 


652  FIBROMYOMA  OF  THE  UTERUS 

progress  over  a  period  of  twenty  years  or  more.  Taking  off  the  first  five  years, 
as  ttie  tumor  may  not  come  under  observation  then,  we  have  fifteen  j^ears  of  the 
growth's  progress  in  which  the  patient  is  likely  to  consult  a  physician.  If  in  a 
mixed  series  observed  during  a  period  of  three  years,  18  per  cent  are  found  to 
have  reached  the  serious  condition  mentioned,  what  per  cent  will  have  reached  the 
same  condition  when  the  same  series  has  been  observed  six  years  or  nine  }■  ears  or 
twelve  years  or  fifteen  j-ears?  Of  course,  it  would  not  be  true  to  assume  that  be- 
cause observation  of  the  series  for  three  years  showed  serious  terminations  in 
IS  per  cent,  observation  of  the  same  series  for  fifteen  years  would  show  serious 
terminations  in  90  per  cent,  but  it  would  be  much  nearer  the  truth  than  the 
assumption  of  18  per  cent  as  the  total  serious  terminations  in  the  300  cases. 

''Physicians  see  but  a  small  number  of  their  fibromyoma  cases  to  the  end.  The 
patient  in  the  earlier  stages  of  the  disease  drifts  from  one  physician  to  another, 
helping  to  swell  the  list  of  patients  'not  requiring  operation'  for  two  or  three  or 
more  physicians.  Later  there  develop  threatening  symptoms  demanding  opera- 
tion, which  is  carried  out.  In  the  records  of  the  last  physician  only  does  the  case 
appear  as  one  'requiring  operation.'  So  from  this  one  case  there  would  be 
statistical  proof  that  operation  is  required  in  only  33  per  cent  of  fibroid  cases.  This 
shows  how  easy  it  is  to  fall  into  serious  eiTor. 

"Tn  looking  up  the  records  of  my  own  fibromyoma  cases,  in  hospital  and  clinic 
and  private  work.  I  find  that  17}4  percent  were  subjected  to  operation.  Opera- 
tion was  advised  in  a  numl^er  of  other  cases,  but  just  how  many  I  cannot  state, 
as  the  recommendations  were  not  alwav-s  recorded.  In  about  two-thirds  of  the 
total  number  of  fibroid  cases  seen,  there  were,  at  the  time,  no  urgent  or  threaten- 
ing symptoms.  But  I  do  not  deceive  myself  with  the  idea  that,  because  these 
patients  were  in  fairly  good  condition  when  last  seen,  they  should  therefore  be 
classed  as  fibroid  cases  that  at  no  time  required  operation.  They  could  not  prop- 
erly be  so  classed  until  traced  to  the  end. 

"Even  in  the  occasional  case  which  is  seen  through  all  stages  by  one  phj^sician, 
the  progress  is  so  slow  and  the  last  stage  is  so  far  removed  from  the  first,  that  the 
relation  of  cause  and  effect  is  in  a  measure  overlooked.  If  the  end  came  in  two  or 
three  years,  as  in  cancer,  it  would  be  impressive,  but  the  first  appearance  of  the 
tumor  and  the  ultimate  result  being  so  far  separated,  the  connection  is  somehow 
lost.  The  case  seems  an  exceptional  one,  some  new  factor  at  work — the  terminal 
condition  can  hardly  be  recognized  as  due  to  the  'harmless'  fibroid  which  the 
patient  has  caiTied  so  many  years  without  particular  trouble. 

'T  mention  these  things  because  I  believe  that  many  are  misled  by  them.  The 
latest  contribution  to  this  part  of  the  subject  that  has  come  to  my  notice,  is  that 
by  Thos.  Wilson,  of  Birmingham..  England.  He  assures  us,  on  practically  the  same 
deceptive  evidence,  viz.,  the  analysis  of  a  series  of  cases  seen  for  a  short  time,  that 
of  fibroids  giving  rise  to  symptoms,  only  30  per  cent  require  removal.  The  re- 
maining 70  per  cent  require  merely  watching  and  minor  palliative  treatment. 

"As  to  what  eventually  becomes  of  this  70  per  cent  he  furnishes  no  proof.  How- 
ever, in  the  recommendations  for  the  care  of  them,  after  giving  directions  for  the 
relief  of  various  distressing  .symptoms,  he  states,  'And,  finally,  operation  sliould  be 
recommended  when  bleeding  gives  rise  to  anemia  and  does  not  yield  to  ordinary 


CHOICE  OF  TREATMENT  653 

treatment;  when  pain  is  severe  and  obstinate;  when  pressure  symptoms,  especially 
retention  of  urine,  occur;  wiien  the  tumor  is  rapidly  increasing  in  size;  and  generally 
when  there  is  evidence  that  the  health  of  the  patient  is  becoming  impaired ' — and 
he  might  have  added,  when  the  kidneys  are  damaged;  when  the  cardio-vascular 
system  is  seriously  affected;  when  the  patient  is  in  bad  condition  for  operation;  and 
when  the  operative  mortality  is  necessarily  high.  I  fail  to  appreciate  the  advan- 
tages of  the  enumeiated  conditions  secured  by  waiting. 

"I  am  anxious  to  get  at  the  real  significance  of  the  facts  presented  on  this  subject. 
I  am  not  interested  in  supporting  any  particular  theory.  I  have  fibromyoma  cases 
to  treat,  however,  and  I  want  to  know  what  is  best  for  them,  and  do  not  intend  to 
be  misled  in  the  matter,  one  way  or  another,  by  taking  facts  to  mean  something  that 
they  do  not  mean,  if  I  can  avoid  it.  I  am  anxious  to  know  all  the  facts  against  early 
operation  as  well  as  all  the  facts  for  it.  I  would  gladly  welcome  any  information 
establishing  the  safety  of  waiting  in  these  cases,  for  no  one  feels  more  than  I  do  the 
responsibility  of  advising  a  patient  in  comparatively  good  health  to  undergo  the 
dangers  of  a  serious  operation. 

"As  to  the  conclusions  in  this  matter,  I  would  urge  that  each  physician  form 
his  own  opinion  after  critical  consideration  of  established  facts— not  hastily,  not 
too  much  influenced  by  the  opinions  of  others,  but  carefully  and  seriously,  as 
one  who  is  personally  responsible  for  the  welfare  of  the  patient. 

"My  own  working  rules  in  this  matter,  are  as  follows: 

"  1.  A  patient  who  has  a  small  fibroid  that  is  causing  no  symptoms,  requires 
no  treatment  for  the  fibroid.  Such  tumors  are  rarely  seen.  Occasionally  one  is 
discovered  in  the  course  of  an  examination  for  symptoms  plainly  due  to  other  cause. 
In  such  a  case  I  usually  do  not  mention  to  the  patient  that  she  has  a  fibroid,  unless 
she  asks  directly  concerning  it,  though  I  take  pains  to  state  the  fact  and  its  bearing 
to  the  husband  or  other  responsible  relative. 

"  2.  A  patient  who  has  a  tumor  of  moderate  size,  causing  only  slightly  trouble- 
some symptoms  which  may  yield  to  general  tonic  treatment  with  the  addition  of 
uterine  astringents  (ergotin,  stypticin),  is  put  on  that  treatment  for  one  to  three 
months — long  enough  to  satisfy  me  as  to  whether  the  symptoms  will  subside 
under  this  treatment.  If  so,  the  treatment  is  continued  as  necessary  to  control 
the  symptoms.  By  'control'  of  the  symptoms  I  do  not  mean  just  to  the  extent 
that  the  patient  can  manage  to  get  along  as  a  semi-invalid,  but  to  such  an 
extent  that  they  are  not  noticeable  to  her — that  she  is  practically  a  well  woman. 

"  If  I  find  the  symptoms  persist  after  a  satisfactory  trial  of  this  treatment,  it 
means  that  they  are  due  largely  to  the  activity  of  the  tumor,  and  not  simply  to 
the  accompanying  pelvic  congestion  (depending  principally  on  some  minor  in- 
flammatory trouble  or  on  constipation  or  on  methods  of  work  or  on  other  cause 
independent  of  the  tumor).  The  persistence  of  symptoms,  after  a  satisfactory 
trial  of  the  measures  to  eliminate  symptoms  due  to  other  causes,  means  that  the 
tumor  itself  is  already  an  active  irritant  in  the  pelvis.  Not  active  in  the  sense 
that  it  is  necessarily  rapidly  enlarging  or  degenerating,  but  active  in  the  sense 
that  it  has  not  passed  into  the  resting,  non-active,  clinically-cured  state,  but  is 
working  the  other  way.     It  is  active  in  the  same  sense  that  a  persisting  appendi- 


654  FIBROMYOMA  OF  THE  UTERUS 

citis  is  active  in  the  quiescent  periods  between  the  acute  attacks.  The  difference 
is  that  the  activity  of  the  fibroid  is  more  insidious,  less  disturbing  for  the  time  being, 
slower,  not  published  by  acute  exacerbations — but  nevertheless  persistently 
progressive. 

"However,  before  recommending  operation  in  a  fibromyoma  case  because  of 
persistent  symptoms,  I  take  pains  to  make  certain  that  the  persistence  of  the 
symptoms  is  due  to  the  tumor,  and  not  to  some  associated  condition  or  conditions 
that  can  be  relieved  by  less  dangerous  meatsures. 

"  Having  established  beyond  doubt  that  the  tumor  itself  is  already  a  continual 
irritant  in  the  pelvis,  I  say  to  the  patient  substantially  as  follows: 

"  'There  is  persistent  trouble  in  spite  of  the  treatment,  and  this  trouble  is  due 
to  the  tumor.  There  is  little  chance  of  its  getting  better  or  of  its  remaining  per- 
manently stationary.  The  strong  probability  is  that  it  will  get  progressively 
worse.  And  it  may  at  any  time  get  rapidly  worse,  and  develop  conditions  that 
would  increase  many  times  the  danger  of  the  operation  which  would  then  be 
necessary  to  save  your  life,  if  it  could  be  saved.  I  am  satisfied  that  the  danger 
of  operation  now  is  much  less  than  the  danger  of  delay.' 

"3.  In  cases  where  the  tumor  is  causing  symptoms  that  plainly  cannot  be  cor- 
rected by  other  measures,  I  at  once  recommend  operation,  without  wasting  time 
with  the  other  measures. 

"  What  about  large  tumors  without  symptoms?  I  am  skeptical  on  the  subject 
of  large  tumors  without  symptoms.  They  are  certainly  very  scarce.  I  do  not 
remember  having  seen  any  case  of  large  fibromyoma  in  which  careful  inquiry  did 
not  show  some  evidence  of  disturbance  from  the  growth  before  it  had  attained  a 
large  size — unless  the  following  case,  seen  recently  in  consultation  with  Dr.  C. 
0.  C.  Max,  of  St.  Louis,  could  be  classed  as  such. 

"The  patient,  a  white  woman,  aged  30,  unmarried,  noticed  in  a  casual  way,  about 
the  middle  of  last  February,  that  the  lower  abdomen  seemed  rather  larger  and 
firm.  Subsequent  developments  indicate  that  the  tum.or  must  have  been  of  con- 
siderable size  at  that  time,  probably  reaching  half  way  to  the  umbilicus.  Careful 
inquiry  elicited  no  noticeable  evidence  of  disturbance  at  that  time,  not  even  bladder 
irritation.  As  the  patient  felt  well  she  paid  no  particular  attention  to  the 
fullness  of  the  abdomen.  At  the  middle  of  March  the  menstrual  flow  was  not  so 
free  as  usual  and,  for  reasons  best  known  to  herself,  she  became  frightened  and 
went  to  a  midwife  who,  March  21,  introduced  a  sound  into  the  uterus  and  assured 
the  patient  there  was  no  pregnancy.  For  two  days  she  worked  and  felt  well. 
The  second  night,  however,  she  had  a  chill  followed  by  fever  and  intermittent 
pains  in  the  abdomen  and  a  bloody  flow  with  clots.  The  trouble  increased  and 
the  patient's  condition  became  serious  and  she  called  in  Dr.  Max,  who  very  properly 
proceeded  to  empty  the  infected  and  partly  emptied  uterus.  But  there  was  not 
much  material  to  be  removed.  The  fever  and  pains  kept  up  and  the  patient's 
condition  became  still  more  serious.  It  was  then  that  I  was  asked  to  see  her  in 
consultation.  Though  it  had  been  only  eight  days  since  the  onset  of  decided  symp- 
toms, the  fibroid  uterus  was  then  as  high  as  the  umbilicus. 

"Thinking  that  possibly  the  acute  infection  was  of  such  character  that  it  would 
quickly  subside,  permitting  a  safer  operation  when  the  virulence  was  spent,  ^\e 


CHOICE  OF  TREATMENT  655 

treated  the  case  accordingly.  But  the  fever  continued  high,  the  abdominal  pains 
increased,  the  pulse  became  rapid  and  the  patient,  instead  of  getting  better,  went 
from  bad  to  worse.  So  we  were  obliged  to  operate,  April  14,  in  the  presence  of 
tiie  acute  infection.  The  specimen  furnishes  a  particularly  clear  illustration  of 
one  of  the  dangers  of  a  sloughing  fibroid,  so  I  brought  it  for  your  inspection 
(Figs.  610,  611).  The  necrotic  fibroid  has  caused  a  perforation  through  the  uter- 
ine wall  into  the  peritoneal  cavity. 

'•'  This  was  one  of  those  mild  cases  that  'get  along  comfortably  and  present  no 
justification  for  subjecting  the  patient  to  the  risks  of  a  serious  operation.'  There 
were  no  threatening  symptoms,  in  fact,  there  were  no  S5^mptoms  of  any  kind  that 
the  patient  had  noticed,  except  a  slight  fullness  in  the  lower  alxlomen.  And  yet 
within  four  weeks  the  pat  rent  was  in  a  most  serious  condition,  and  had  to  be  operated 
on  in  that  condition  with  the  greatly  increased  risk. 

''There  was  a  streptococcus  infection,  causing  sloughing  of  the  fibroid,  and  the 
large  sloughing  fibroid  had  caused  perforation  of  the  uterine  wall,  destroying  an 
area  as  large  as  a  silver  dollar,  as  here  shown.  The  omentum  was  adherent 
over  this  opening.  When  the  adhesions  were  partially  separated  the  bloody  in- 
fected fluid  from  around  the  necrotic  fibroid  poured  out  into  the  peritoneal 
cavity.  This  gives  an  idea  of  the  desperate  character  of  the  case.  The  oper- 
ation was  total  hysterectomy.  On  account  of  the  extensive  infection,  involving 
the  peritoneal  cavity,  we  drained  freely  both  into  the  vagina  and  through  the 
abdominal  incision.     The  patient  recovered,  but  it  was  a  close  call  for  her. 

"Returning  to  the  general  subject  of  advice  to  fibromyoma  patients,  the  three 
worldng  rules  just  given  very  readily  incUcate  in  most  cases  whether  the  tumor 
should  be  let  alone  or  removed.  I  refer  to  the  general  run  of  cases — the  common 
forms  of  myoma  in  patients  under  ordinary  circumstances. 

"There  are,  of  course,  certain  exceptional  cases  in  which  there  must  be  taken  into 
consideration  special  conditions  —  in  the  fibromyomatous  uterus  or  in  the  age  or 
physical  condition  of  the  patient  or  in  her  surrounding  circumstances.  For 
example,  if  the  uterus  is  pregnant  and  the  tumor  is  of  such  size  and  situation  that 
it  vnW  probably  not  interfere  with  pregnancy  and  parturition,  I  would  not  interfere 
at  that  time.  If  the  patient  is  in  the  menopause  or  safely  through  that  period, 
I  would  feel  justified  in  leaving  some  growths  that  I  would  not  leave  in  a  younger 
woman.  Again,  a  patient  may  be  in  circumstances  in  which  it  is  important  that 
for  a  time  she  take  no  risk,  not  even  a  small  one,  unless  absolutely  forced  into  it 
by  the  most  threatening  conditions,  as  when  she  has  small  children  wholl}' 
dependent  on  her  for  the  time  being.  Again,  the  distribution  of  the  tumor  tissue 
has,  in  certain  cases,  a  considerable  influence  on  the  decision,  for  example,  a  patient 
presenting  several  good-sized  nodules  in  the  uterine  vv^all  can  wait  with  more  safety 
than  where  the  same  amount  of  fibromyomatous  growth  is  collected  in  one  or  two 
large  tumors.  There  are  many  such  special  conditions  that  must  be  taken  into 
consideration.  This  is  true  to  such  an  extent  that,  in  a  measure,  each  case  re- 
quires particular  consideration  and  decision.  This  is  the  reason  why  it  is  impos- 
sible to  formulate  rules  applicable  to  all  cases. 

"However,  we  necessarily,  even  in  the  exceptional  cases,  base  our  advice  largely 
on  some  general  guiding  principles.     And  it  behooves  us  to  be  certain  that  those 


656  FIBROMYOMA  OF  THE  UTERUS 

general  principles  accord  with  the  facts  (the  real  facts  and  not  the  supposed  facts; 
as  far  as  the  facts  are  known. 

"In  closing  I  wish  to  emphasize  the  following  points: 

"1.  A  fibroid  tumor  of  the  uterus,  which  has  reached  a  size  to  be  appreciated 
clinically,  is  a  much  more  serious  affection  than  is  generally  supposed. 

"A  considerable  proportion  of  the  patients  develop  fatal  local  conditions,  another 
considerable  proportion  develop  serious  distant  visceral  degenerations,  and  a  large 
proportion  of  the  remainder  (possibly  most  of  them)  finally  pass  into  a  condition 
of  chronic  suffering  and  invalidism. 

"2.  The  progress  of  the  disease  is  so  slow  as  to  be  deceptive,  many  cases  taking 
fifteen  to  twenty  years  to  reach  full  development — hence  the  serious  results  do  not 
appear  in  the  observation  of  a  series  of  cases  for  a  few  years,  a  few  years  constituting 
but  a  fraction  of  the  developmental  period. 

"Yet  the  wide-spread  teaching  that  serious  conditions  develop  in  only  a  very 
small  proportion  of  the  cases,  is  based  largely  on  just  such  limited  observations, 
recorded  and  unrecorded.  No  large  series  of  consecutive  cases  followed  to  the 
end  without  operation  has  shown  a  small  mortality. 

"3.  Uterine  fibroid  kills  principally  by  inducing  serious  local  and  general  com- 
plications, that  go  down  in  the  mortuary  records  as  the  cause  of  death — hence 
mortuary  records  give  no  indication  of  the  ravages  of  the  disease.  It  kills  secretly 
and  indirectly,  but  none  the  less  surely. 

"4.  The  proportion  of  the  various  classes  that  (a)  go  on  to  a  fatal  termination 
or  (b)  become  chronic  sufferers  and  invalids  or  (c)  develop  no  serious  symptoms, 
can  be  exactly  determined  only  by  securing  accurate  records  of  a  large  series  of 
cases,  comprising  all  classes,  from  the  beginning  of  the  trouble  to  the  end. 

"5.  Enough  is  already  known  to  show  that  delay  is  dangerous.  Many  patients 
develop  fatal  conditions,  many  find  operation  necessary  when  in  such  a  state  as 
to  make  the  operation  exceedingly  dangerous,  and  some  must  be  refused  operation 
because  of  advanced  complications —  nearly  all  of  which  loss  of  life  and  health  could 
have  been  prevented  by  early  operation. 

"6.  The  chance  of  satisfactory  improvement  after  the  menopause  is,  speaking 
generally,  more  than  overbalanced  by  the  frequency  of  serious  degenerative 
changes  and  complications. 

"7.  We  assume  a  grave  responsibility  when  we  advise  a  patient  to  wait  until 
serious  symptoms  develop  before  having  the  tumor  removed. 

"Early  operation,  under  proper  conditions,  means  small  risk  to  the  patient. 
Late  operation  means  great  risk." 

PREGNANCY  AND  FIBROID. 

The  association  of  fibromyoma  with  pregnancy  is  always  a  matter  for  serious 
concern,  though  many  patients  get  along  without  trouble.  Lafour,  in  a  series  of 
300  cases  of  fibroid  and  pregnancy  in  which  delivery  took  place  by  way  of  the 
birth  canal,  found  the  maternal  mortality  40%  and  the  infantile  mortality  77%. 
In  a  series  of  147  cases  of  fibroid  and  parturition,  collected  by  Susserott,  the 
maternal  mortality  was  53%  a,nd  the  infantile  mortaUty  66%.  In  20%  of  these 
cases  forceps  were  used,  with  the  loss  of  8  mothers  and  13  children. 


TREATMENT  WHEN  COMPLICATED  BY  PREGNANCY  657 

"Johnston  estimated  that  thn-ing  pregnancy  or  hibor  one-third  of  the  mothers 
and  more  than  one-half  of  the  children  die,  and  recommends  celibacy  when  the 
tumor  can  not  be  removed."  Rosenwasser  said  in  1899  that  antisepsis  and  im- 
proved technique  had  reduced  the  maternal  mortality  only  to  37%. 

Methods  of  Treatment. 

1.  Non=mterference.  The  patient  is  allowed  to  go  along  until  term,  in  the 
hope  that  there  may  then  be  a  satisfactory  delivery  (spontaneous  or  operative). 
As  mentioned  later,  this  is  the  preferable  plan  in  many  cases.  The  results  have 
been  reported  in  various  series  of  cases,  as  follows: 

Spontaneous  delivery.  In  a  series  of  84  cases  of  labor  complicated  by  fibroids, 
64%  of  the  patients  managed  to  deliver  themselves,  while  36%  required  assistance 
by  forceps  or  otherwise. 

Forceps,  In  Veit's  series  of  39  forceps  cases,  the  maternal  mortality  was 
33%  and  the  infantile  mortality  was  the  same. 

Version.  In  Veit's  series  of  87  version  cases,  the  maternal  mortality  was  64% 
and  the  infantile  mortality  82%. 

In  fibroid  cases  there  seems  to  be  a  marked  tendency  to  adherent  placenta. 
In  a  series  of  147  cases  of  fibroid  complicating  labor,  manual  removal  of  the  pla- 
centa was  necessary  in  21  cases,  and  13  of  these  women  died.  This  serves  to  call 
attention  to  the  difficulties  of  this  condition,  which  is  always  a  serious  one  in  the 
presence  of  a  fibroid. 

Caesarian  section.  In  Sanger's  series  of  43  cases,  the  maternal  mortality  was 
83.7%  and  in  Pozzi's  28  cases  the  maternal  mortaUty  was  86%.  In  48  Porro 
operations  in  fibroid  patients,  the  maternal  mortality  was  33%.  In  a  later  series 
of  49  cases  of  the  Porro  operation  in  fibroid  patients,  the  maternal  mortality  was 
only  12.5%,  showing  that  immediate  removal  of  the  fibromyomatous  uterus  is 
the  safer  operation. 

2.  Myomectomy.  The  patient  is  subjected  to  operation  for  the  removal  of  the 
tumor,  but  the  pregnancy  is  allowed  to  continue — if  it  will.  Leopold,  in  his 
myomectomies  in  the  pregnant  uterus,  from  1884  to  1894,  had  a  maternal  mor- 
tality of  17.4%  and  a  fetal  mortality  of  37.6%.  Stavely  had  a  maternal  mor- 
tality of  24.2%.  The  probability  of  abortion  is  great  and  must  never  be  lost 
sight  of,  though  many  cases  of  extensive  myomectomy  have  recovered  without 
abortion.  Olshausen  reported  21  myomectomies.  Abortion  followed  in  38%. 
In  a  series  of  57  myomectomies  and  enucleations  during  pregnancy,  12%  of  the 
w^omen  died  and  24%  aborted. 

3.  Hysterectomy.  The  fibromyomatous  uterus  is  removed  in  early  pregnancy. 
In  a  recent  series  of  89  cases  of  supravaginal  hysterectomy  for  fibroid  complicated 
by  pregnancy,  the  mortality  was  11%.  When  the  operation  is  canied  out  promptly 
(before  serious  complications  intervene)  the  mortality  is  very  little  higher  than 
hysterectomy  in  the  non-pregnant. 

4.  Induced  abortion.  As  the  patient  is  in  a  serious  condition  and  her  life  threat- 
ened, the  plan  of  emptying  the  uterus  has  been  suggested  and  carried  out.  Lafour 
collected  39  cases  of  fibroid  and  pregnancy  in  which  this  method  of  treatment  was 


(358  FIBROMYO:\IA  OF  THE  UTERUS 

employed.  The  mortality  was  36%.  In  the  case  of  a  fibromyomatous  uterus 
the  dangers  from  abortion  (spontaneous  or  induced)  are  great,  because  of  the 
difficulty  of  completely  emptying  the  uterus  and  the  consequent  frequency  of 
hemorrhage  and  sepsis. 

Selection  of  treatment. 

The  treatment  to  be  employed  depends  on  the  size  and  location  of  the  fibro- 
myoma  and  the  stage  of  pregnancy  at  which  the  patient  is  seen. 

When  the  tumor  is  in  the  upper  part  of  the  uterus  and  is  of  small  or  medium  size 
and  not  causing  much  trouble,  it  should  be  let  alone  until  after  parturition. 

When  the  tumor  is  so  large  or  so  situated  (cervix  fibroid)  that  it  precludes 
the  possibility  or  probability  of  full-term  delivery  per  via  naturalis,  the  treatment 
turns  somewhat  on  the  stage  of  pregnancy.  ^  If  the  patient  is  seen  in  early  preg- 
nancy, hysterectomy  is  the  safest  plan  of  treatment.  In  some  exceptional  cases 
the  tumor  may  be  so  situated  that  myomectomy  (abdominal  or  vaginal),  with 
hope  of  continuing  the  pregnancy,  is  justifiable. 

If  the  patient  is  first  seen  in  late  pregnancy,  it  may  be  advisable  to  postpone 
operation  until  full  term  or  nearly  full  term,  with  the  hope  of  saving  the  child 
by  Caesarian  section. 

Of  course,  there  are  all  gTadations  in  seriousness,  from  the  cases  where  it  is 
almost  certain  that  there  will  be  no  trouble  to  the  cases  in  which  full-term  delivery 
by  the  natural  route  would  be  absolutely  impossible.  It  is  the  middle  class  that 
contains  the  cases  that  furnish  the  most  puzzling  problems.  When  seen  in  early 
pregnancy  there  is  an  uncertain  factor,  namely,  the  probable  extent  of  develop- 
ment of  the  fibroid  during  pregnancy.  This  makes  it  difficult  in  some  cases^  to 
decide  just  which  line  of  treatment  is  preferable.  In  cases  of  doubt  after  giving 
due  consideration  to  the  various  aspects  of  the  case,  the  rule  is  to  await  develop- 
ments. . 

A  numerous  class  of  fibroid  cases  complicated  by  pregnancy,  is  that  m  which 
the  patient  has  one  or  more  fibroids  that  give  no  particular  trouble  until  she  be- 
comes pregnant.  After  the  patient  has  been  pregnant  three  or  four  months 
the  symptoms  become  so  acute  and  threatening  that  the  tumor  and  uterus  must 
be  removed  or  the  uterus  must  be  emptied,  with  the  dangers  incident  to  miscar- 
riage in  these  cases  (see  above)  and  the  probability  of  operative  removal  of  the 
tumor  and  uterus  later.  I  think  immediate  hysterectomy  is  the  safest  plan  under 
these  circumstances.  The  choice  of  the  treatment  in  such  cases  is  discussed  in 
detail  in  a  paper  I  read  before  the  St.  Louis  Medical  Society  in  1901.* 

LIPOMA  OF  THE  UTERUS. 

Lipoma  of  the  uterus  is  rare,  so  rare  as  to  constitute  a  curiosity.  A  few  case« 
have  been  reported,  one  of  which  is  shown  in  Fig.  361.  A  lipoma  in  the  uten/- 
wall  may  come  without  particular  cause,  as  in  other  situations,  or  it  may  come 
from  fatty  degeneration  of  a  fibroid.  Tiio  symptoms  and  treatment  are  practically 
the  same  as  for  fibromyoma.  The  exact  diagnosis  is  made  after  the  mass  is  re- 
moved and  laid  open. 

*  Report  of  Two  (^usos  of  rrcgniincy  Kequiring   Operation,  by  H.    S.  Crossen,    M.D.    St. 
Louis  Medical  Review,  Avig.    24,  1901. 


659 


CHAPTEK  IX. 

MALIGNANT  DISEASE  OF  THE  UTERUS. 

Malignant  disease  of  the  uterus  occurs  in  the  form  of  carcinoma  and  sarcoma. 
Carcinoma  of  the  cervix  uteri  is  so  different  cUnically  from  carcinoma  of  the 
corpus  uteri,  that  I  think  advisable  to  consider  the  two  separately.  The  sub- 
ject of  this  chapter  then  may  be  divided  into  three  parts,  as  follows: 

Carcinoma  of  the  Cervix  Uteri. 

Squamous-cell  Carcinoma  (Epithelioma). 
Cylindrical-cell  Carcinoma  (Adeno-carcinoma). 
Malignant  Adenoma. 
Endothelioma. 

Carcinoma  of  the  Corpus  Uteri. 

Adeno-carcinoma. 
Malignant  Adenoma. 
Endothelioma. 
Chorio-epithelioma. 

Sarcoma  of  the  Uterus  (Cervix  and  Corpus). 
CARCINOMA  OF  THE  CERVIX  UTERI. 

This  term  signifies  malignant  disease  of  epithelial  origin,  situated  in  the  cervix. 
It  may  arise  from  the  squamous  epithelium  covering  the  vaginal  surface  of  the 
cervix,  in  which  case  it  is  a  squamous-cell  carcinoma  and  is  ordinarily  designated 
as  "epithelioma."  It  may  arise  from  the  glandular  epithelium  in  the  interior 
of  the  cervix,  in  which  case  it  is  a  cylindrical-cell  carcinoma  and  is  ordinarily 
designated  as  "adeno-carcinoma." 

ETIOLOGY. 

The  cause  of  carcinoma,  as  of  other  forms  of  new  growth,  is  still  a  mystery. 
As  in  the  case  of  fibromyoma,  there  are  some  interesting  theories  but  they  are 
still  theories  only. 

P.ATHOLOGY. 

Cancer  of  the  uterus  is,,  in  the  beginning,  essentially  a  local  process.  The  ap- 
parently independent  gi'owths  appearing  later  in  various  organs,  are  simply 
metastases  from  the  primary  tumor.  This  fact  has  been  firmly  established  by 
the  most  thorough  and  painstaking  investigation  by  many  authorities.     The 


660 


MALIGNANT  DISEASE  OF  THE  UTERUS 


supposition  that  it  is  simpl}-  the  local  manifestation  of  some  constitutional 
dyscrasia,  has  no  foundation.  The  important  bearing  of  this  on  treatment  is 
apparent. 

Frequency.  As  far  as  known  at  present,  primary  carcinoma  occurs  more  fre- 
quently in  the  uterus  than  in  any  other  organ,  carcinoma  of  the  stomach  coming 
next  in  frequency.     Welch  found  in  a  series  comprising   31,000  carcinoma  cases 


Fig.  616.  A  Small  Epithelioma  of  the  Cervix  Associated  with  Fibromyoma  of  the  Corpus 
Uteri.  In  this  case  the  most  evident  lesion  was  the  fibroid,  but  further  examination  revealed 
induration  and  irregularity  about  the  external  os,  with  some  bleeding  on  examination.  A 
piece  of  tissue  exci.scd  from  the  suspicious  area  and  submitted  to  microscopic  examination  show- 
ed epithelioma.     The  specimen  is  shown  sectioned  in  Fig.  617. 


that    the  primary  growth  was    in  the  uterus    in  approximately  29%  and    in  the 
stomach  in  21%. 

Most  carcinomata  of  the  uterus  occur  iu  the  cervix.  Cullen,  in  a  strict  analysis 
of  his  128  cases  of  carcinoma  of  the  uterus,  found  that  74  were  epitheliomata  of 
the  cervix,  19  were  adeno-carcinomata  of  the  cervix  and  35  were  adeno-carcino- 
mata  of  the  corpus  uteri.  The  great  frequency  of  carcinoma  in  the  cervix  is 
supposed   to    l)e    due  largely  to    injuries   there  in  child-bearing,  with  resulting 


PATHOT.OGY  OF  CARCINOMA  OF  CERVIX  661 

scar-tissue,  inflammation,  cystic  degeneiation  and  chronic  irritation.  It  is  rare 
in  the  uninjured  cervix,  though  some  cases  have  been  reported,  even  in  children. 

Varieties.  Carcinoma  of  the  cervix  occurs  in  two  principal  forms — epithelioma 
(squamous-cell  cancer)  and  adeno-carcinoma  (cylindrical-cell  cancer),  the  epithel- 
ioma being  by  far  the  more  frequent  (74  to  19  in  Cullen's  cases). 

Epithelioma  of  the  cervix  originates  from  the  squamous  epithelial  cells  cover- 
ing the  vaginal  portion.  Arising  from  that  part  of  the  cervix  known  as  the  "  portio 
vaginalis,"  it  is  sometimes  spoken  of  as  "cancer  of  the  portio." 

The  disease  begins  as  a  small  area  of  infiltration  on  the  vaginal  surface  of  the 
cervix,  supposedly  at  a  point  of  persistent  irritation  from  scar-tissue  or  erosion 
or  other  irritating  process.  If  the  patient  happens  to  be  examined  at  this 
stage,  the  infiltrated  spot  feels  rather  firm  to  the  touch.  That  is  all.  There  is 
no  pain,  there  may  be  no  bleeding  or  discharge,  though  there  may  be  some  discharge 
from  the  preceding  chronic  irritation.  As  far  as  the  naked-eye  appearance  is  con- 
cerned, it  does  not  differ  materially  from  a  small  area  of  chronic  inflammatory 
infiltration  or  erosion.  The  essential  pathological  change  is  that,  at  the  point 
indicated,  the  squamous  epithelium  is  beginning  to  penetrate  into  the  underlying 
connective  tissue.  This  invasion  is  resisted  by  the  leucocytes  which  collect  in 
the  adjacent  tissue.  As  the  process  continues,  the  carcinomatous  infiltration,  with 
the  opposing  round-cell  (leucocyte  and  lymphocyte)  infiltration,  penetrates  deeper 
into  the  tissues  and  the  small  area  of  induration  gradually  increases  in  extent.  A 
small  abrasion  or  ulcer  appears  (Figs.  616,  617,  443).  This  usually  bleeds  slightly 
when  touched.  Frequently  the  first  evidence  of  anything  wrong  that  the  pa- 
tient notices,  is  a  slight  streak  of  blood  or  spot  of  blood  after  coitus  or  after  extra 
walking  or  other  exertion.  This  may  remain  the  only  external  evidence  of  the  dis- 
ease for  many  months — in  fact,  in  a  considerable  proportion  of  the  cases,  no  other 
symptoms  appear  until  the  disease  has  penetrated  deeply  into  the  cervix  and  out 
into  the  parametrium. 

As  the  disease  extends  in  the  cervix,  more  infiltration  becomes  appreciable  on 
palpation  and  more  ulceration  (which  may  be  mistaken  for  laceration  or  erosion) 
may  be  seen  through  the  speculum  (Figs.  618,  445). 

Still  later  there  may  be  ulceration  into  the  rectum  or  bladder  (Fig.  619),  forming 
fistulae  which  add  greatly  to  the  patient's  suffering. 

As  the  disease  advances,  projecting  growth  may  occur,  causing  distinct  papillary 
outgrowths  on  the  affected  portion  of  the  cervix  (Fig.  447).  Still  later  the  cervix 
may  be  replaced  by  a  papillary  fungus  tumor-mass.  On  the  other  hand,  particularly 
in  the  aged  with  very  slow-growing  epitheliomata,  the  formation  of  contracting 
scar-tissue  may  so  draw  in  the  affected  region  that  it  can  not  be  seen.  In  such 
a  case  it  can  be  appreciated  only  by  palpation,  which  reveals  induration  at  the 
vaginal  vault  (Fig.  446). 

In  addition  to  the  regular  and  essential  elements  of  the  diseased  tissue,  there 
may  be  secondary  changes.  Areas  of  softening  and  degeneration  occur  in  which 
the  cells  are  broken  down  and  become  simply  fluid  and  debris.  Hemorrhage 
into  certain  parts  of  the  growth  may  occur  and,  as  a  result  of  that  hemorrhage, 
there  remain  clots  and  discoloration  and  fluid.  Infection  may  take  place,  leading 
to  suppuration  or  sloughing.     Occasionally  lime  salts  are  deposited  in  the  cancer 


662 


MALIGNANT  DISEASE  OF  THE   UTERUS 


cells.     This  chalky  deposit   may   be  extensive  and   may  even   be  found  in  the 
metastases. 

Adeno=carcinoma  of  the  cervix  arises  from  the  cylindrical  cells  lining  the  interior 
of  the  cervix  and  forming  the  cervical  glands.  It  may  then  in  the  beginning  be 
located  at  the  external  os  or  in  the  cervical  canal  or  in  any  part  of  a  gland 
extending  deeply  into  the  cervical  wall.  As  the  cell-columns  penetrate  the  under- 
lying tissues,  the  cells  assume  somewhat  a  gland  formation  owing  to  this  deriva- 
tion from  gland-forming  epithelium.  This  gland  formation,  however,  is  very 
irregular  and  atypical,  being  represented  to  a  large  extent  only  by  solid  columns 


Fig.  617.       An  Antero-posteiior  Section  of  the  specimen  sliown    in  Fig.  616.       Microscopic  examination 
showed  that  the  epithelioma  extended  along  the  cervical  canal  practically  to  the  internal  os. 


of  cells.     "Malignant  adenoma"'  is  a  rare  form  of  adcno-carcinoma  in  which  the 
penetrating  cells  preserve,  to  a  marked  extent,  the  glandular  arrangement. 

The  infiltration  in  adeno-carcinoma,  being  situated  in  the  interior  of  the 
cervix,  is  not  appreciatcnl  by  the  examining  finger  until  a  considerable  mass  has 
formed.  The  disease  pursues  much  the  same  general  course  as  described  for  epithe- 
lioma, the  carcinoma  cells  penetrating  deeper  and  deeper  into  the  cervix  and  into 
the  surrounding  connective  tissue  (Fig.  620). 


I'ArilULOGV  OF  CARCINOMA  OF  CEUVIX 


663 


Endothelioma  is  a  rare  form  of  malignant  disease  of  the  cervix  in  which  micro- 
scopic examination  shows  spaces  Uned  with  proUferating  cells  resembling  endo- 
thelium. Its  exact  nature  and  origin  have  not  been  determined — in  fact,  it  is  still 
uncertain  whether  it  is  an  epithelial  growth  (carcinoma)  or  a  connective-tissue 
growth  (sarcoma). 

Modes  of  extension.  Carcinoma  of  the  cervix  extends  in  four  ways — by  con- 
tinuity of  tissue,  by  the  lymphatics,  by  the  blood-stream  and  by  implantation. 


Fig.  618.      An  Epithelioma  of  the  Cervix  Uteri,  advanced  to  stage  of 
the  destruction  of  the  cenux.     (Cullen — Cancer  of  the   Uterus.) 


Extension  by  continuity  of  tissue  is  the  principal  method  and,  aside  from  ex- 
ceptional cases,  the  only  method  in  the  earlier  stages  of  the  growth.  In  tliis  method 
of  extension,  the  carcinoma  cells  grow  into  the  tissues  against  which  they  lie. 
This  differs  markedly  from  the  way  in  which  a  non-malignant  tumor  extends. 
A  fibro myoma  as  it  grows,  pushes  aside  the  adjacent  tissues,  but  a  malignant 
tumor  as  it  grows  penetrates  the  adjacent  tissues  and  destroys  them. 

It  is  this  insidious  involvement  of  contiguous  tissues  that  makes  many  cervical 
carcinomata  inoperable  when  first  seen.     It  i.s  this  same  gradual  extension  outward 


664 


MALIGNANT  DISEASE  OF  THE  UTERUS 


by  continuity  of  tissue  that  later  causes  the  patient  most  of  her  suffering  and 
that  in  most  cases  causes  her  death,  by  involving  the  uterus  or  bladder  or  rectum. 

In  extension  through  the  lymphatics,  some  carcinoma  cells  are  caught  in 
the  lymph  current  and  canied  to  lymphatic  glands,  where  they  lodge  and  grow 
and  destroy  tissue  the  same  as  the  parent  growth.  This  invasion  of  the  lymphatic 
glands  by  carcinoma  cells  does  not  occur  usually  until  rather  late  in  the  disease — 
until  it  has  extended  by  continuity  of  tissue  through  the  cervix  into  the 
parametrium. 

Winter  found  cancerous  glands  in  only  2  cases  in  44  autopsies  on  patients  where 


Fig.  619.  An  Epithelioma  of  the  Cervi.K  Uteri,  still  farther  advanced. 
The  growth  has  invaded  the  bladder  and  rectum,  causing  fistulae  into  these 
organs.     (Cullen — Cancer  of  the  Uterus.) 


the  disease  was  confined  to  the  uterus.  Wertheim,  in  60  operated  cases,  found 
involvement  of  removed  glands  in  15  percent  of  early  cases  and  in  31.7  per  cent 
of  all  cases.  Schauta  made  a  most  thorough  autopsy-study  of  60  cases,  in  40  of 
which  the  patients  died  from  the  natural  effects  of  the  cancer  and  in  9  from  inter- 
current affections.  In  43.3  per  cent  of  the  whole  series,  the  glands  were  entirely 
free  of  carcinomatous  metastases,     The  lower   (removable)   glands  alone  were 


PATHULUGV  OK  (JAHCINOMA  UK  CI;K\IX 


665 


involved  in  13.3  per  cent,  the  upper  (not  removable)  glands  alone  in  8.3  per  cent 
and  both  lower  and  upper  glands  in  35  per  cent. 

Kundradt,  in  a  study  of  76  cases  operated  on  by  Wertheim,  in  which  the  para- 
metrium was  involved  on  one  or  both  sides,  found  the  glands  entirely  free  of 
metastases  in  71  per  cent.  The  glands  on  one  side  were  involved  in  22  per  cent, 
and  the  glands  on  both  sides  were  involved  in  7  per  cent. 

The    glands  are    rarely    involved    until    the  cancer  has    advanced  into    the 


Fig.  620.     .\dvanced  Adeno-carcinoma  of  the  Cervix  Uteri.     Notice  the  involvement  of  the  parametrium. 
(Kelly — Operative  Gynecology.) 


parametrium.     Kundradt,  in  his  analysis  of  80  cases,  found  only  four  in  which 
the  glands  were  involved  with  the  parametrium  free. 

Enlargement  of  the  regional  glands  is  very  common  in  the  early  stage  of  carci- 
noma but  this  enlargement  is,  as  a  rule,  not  due  to  carcinoma  cells  but  to  the  in- 
flammatory hypertrophy  that  nearly  always  takes  place  in  the  glands  draining 
a  region  that  is  subject  to  severe  chronic  irritation.     In  exceptional  cases,  how-. 


666  MALIGNANT  DISEASE  OF  THE  UTERUS 

ever,  the  glands  may  become  infected  with  carcinoma  cells  at  an  early  stage  of 
the  disease. 

This  matter  of  glandular  involvement  has  a  very  important  bearing  on  the 
question  of  operative  treatment. 

In  extension  by  the  blood  stream,  some  carcinoma  cells  penetrate  into  a 
blood-vessel,  are  caught  in  the  current  and  are  carried  to  distant  organs,  where 
they  lodge  and  grow  and  form  metastatic  tumors.  In  whatever  kind  of  tissue  these 
metastatic  growths  are  situated,  they  reproduce  the  structure  of  the  parent  growth. 
The  lungs  arc  most  frequently  affected,  though  there  are  many  other  organs  that 
are  affected  occasionally.  The  possibility  of  metastases  must  be  kept  in  mind 
in  deciding  whether  or  not  a  case  is  operable.  If  metastasis  to  distant  organs  has 
occurred,  hysterectomy  would  of  course  be  useless,  except  as  a  palliative  measure. 
However,  such  metastases  almost  never  occur  except  in  the  last  stage,  and  then 
not  very  frequently.  Winter,  in  202  cases,  found  metastases  in  distant  organs  in 
only  23'i2  per  cent. 

Direct  implantation  of  cancer  cells  into  the  healthy  tissues  of  a  raw  surface 
takes  place  principally  in  operations  for  cancer — the  cells  being  carried  on  the 
knife  or  scissors  or  other  instrument,  or  on  the  fingers  or  sponges,  from  the  infil- 
trated area  to  the  healthy  tissue  which  has  been  laid  open  in  the  operative 
work.  Many  undoubted  instances  of  this  occurrence  are  on  record.  It  furnishss 
a  strong  reason  for  keeping  entirely  clear  of  the  involved  area  in  operations  for 
the  cure  of   cancer. 

Complications.  Aside  from  the  tumor  itself,  there  are  several  conditions  re- 
sulting from  it  that  enter  into  the  pathological  and  clinical  picture.  The  ureters 
may  be  compressed,  leading  to  dilatation  of  the  ureters  and  also  to  hydronephrosis 
(Fig.  621).  In  the  later  stages  there  is  compression  of  the  pelvic  nerves  and  ves- 
sels, causing  pains  and  edema.  The  infiltration  may  penetrate  the  wall  of  the 
bladder  or  rectum,  and  if  the  infiltrated  tissues  break  down,  fistulae  into  these 
organs  are  formed  (Fig.  619). 

Associated  diseases  also  add  to  the  pathological  picture  in  certain  cases.  Fibro- 
myoma  of  the  uterus  is  a  rather  frequent  association  (Figs.  616,  421).  Various 
inflammatory  lesions  are  frequent  and  add  much  to  the  danger  and  difficulties 
of  operative  treatment. 

Duration  of  the  disease.  .  This  is  variable,  the  limits  ordinarily  being  one  to 
three  years.  The  duration  depends  somewhat  on  the  kind  of  tumor  (the  softer  the 
tumor  the  more  rapid  the  growth),  upon  the  age  of  the  patient  (the  younger 
the  patient  the  more  rapid  the  growth)  and  upon  the  proximity  to  child-birth — 
those  carcinomata  appearing  within  one  year  after  parturition  progressing  very 
rapidly. 

These  arc  only  general  rules,  to  which  there  arc,  of  course,  exceptions. 

Effect  of  pregnancy.  Sometimes  carcinoma  of  the  cervix  may  appear  while 
the  patient  is  pregnant,  or  occasionally  pregnancy  may  take  place  in  the  earl}' 
stage  of  carcinoma  of  the  cervix.  In  either  case  the  effect  of  pregnancy  is  to  hasten 
the  progress  of  the  carcinoma.  The  softening  of  the  tissues  and  the  cojigestion 
associated  with  pregnancy,  seem  to  favor  rapid  extension  of  the  malignant  dis- 
ease. 


DIl  FERENTIAL  DIAGNOSIS  OF  MALIGNANT  DISEASE 


667 


Fig.  621.  Dilatation  of  the  Ureters  and  Kidneys,  due  to  obstruction 
of  the  ureters  by  Cancer  of  the  Cenis  Uteri.  {Kelly— Operative  Gyne- 
cology.) 


SYMPTOMS   AND   DIAGNOSIS. 

The  first  symptom,  in  practically  all  cases  of  carcinoma  of  the  cervix  is  a  slight 
ieucorrhoeal  discharge,  with  an  occasional  spot  of  blood.  This  shght  streak  of 
blood  is  seen  usually  after  extra  exertion  (extra  work,  long  walk,  lifting)  or  after 
a  douche  or  after  coitus.  It  is  especially  liable  to  appear  within  24  hours  after 
coitus.  A  history  of  such  "spotting"  of  the  discharge  or  of  the  clothing,  calls  for 
a  most  careful  examination,  that  the  presence  or  absence  of  carcinoma  of  the 
vaginal  surface  of  the  cervix  or  of  the  interior  of  the  cervix,  may  be  certainly 
determined. 

In  giving  the  symptoms  and  the  diagnosis  of  this  disease,  I  shall  speak  nearly 
altogether  of  the  early  stage.  It  is  in  this  stage  that  the  diagnosis  is  most  diffi- 
cult and  it  is  in  this  stage  that  the  diagnosis  is  most  important,  for  operation  then 
will,  in  a  large  proportion  of  the  cases,  save  the  life  of  the  patient.  In  this 
connection  it  \Aill  be  an  advantage  to  consider  the  differential  diagnosis 
between  the  early  stage  of  malignant  disease  of  the  uterus  in  (jenerul  (Ijoth  carei- 


668  MALIGXA.VT   DISEASE  OF  THE  UTERUS 

noma  and  sarcoma)  and  the  conditions  T^ith  ^'liich  it  is  likely  to  be  confused. 
This  is  a  very  important  subject,  particularly  to  the  general  practitioner  who 
usually  sees  the  patient  first  and  upon  whom  rests  the  responsibihty  of  recognizing 
mahgnant  disease  in  its  beginning,  or  of  recognizing  the  cases  in  which  it  may 
be  present  and  which  require  special  investigation  accordingly. 

Concerning  early  diagnosis  of  malignant  disease  of  the  uterus,  I  quote  from  a 
paper  of  mine  pubhshed  in  1900:* 

'■'How,  then,  are  we  to  discharge  our  responsibilities  in  this  matt-er?  We  can 
not  curet  even,^  woman  that  comes  to  us,  nor  excise  and  examine  a  piece  of  the 
cervix,  simply  because  she  might  have  cancer. 

"  What  is  needed  is  the  adoption  of  a  practical  mode  of  procedure  for  determin- 
ing certainly,  in  patients  -v^ith  uterine  disease,  whether  or  not  mahgnant  infiltra- 
tion is  present. 

''Malignant  di.sease  of  the  uterus  means  carcinoma  or  sarcoma.  Carcinoma  may 
start  from  the  squamous  epithehum  covering  the  cervix  or  from  the  cyhndrical 
epithelium  lining  the  canal  of  the  cervix  and  body  of  the  uterus  or  from  the  gland- 
cells  situated  deeply  in  the  substance  of  the  cervix  and  body.  Sarcoma  may  start 
from  any  part  of  the  organ. 

"]\Ialignant  trouble  is  invariably  chronic  and  there  is  always  present  either 
induration  or  ulceration. 

"In  the  CERVIX,  if  there  is  induration  it  can  be  felt.  If  there  is  ulceration  or 
erosion  of  the  outer  surface  of  the  cer\ix  it  can  be  seen.  If  there  is  ulceration  within 
the  cer^■ical  canal  it  will  cause  a  troublesome  discharge. 

"In  the  BODY  of  the  uterus,  if  there  is  ulceration  it  will  cause  a  troublesome  dis- 
charge. By  "troublesome  discharge"  I  mean  what  is  ordinarily  called  "leucor- 
rhoea" — not  the  watery  discharge  of  advanced  cancer.  Induration  in  the  body 
of  the  uterus  can  not,  of  course,  be  detected  until  a  considerable  mass  has  formed. 
I  am  satisfied,  however,  that  practically  even,-  case  of  malignant  disease  of  the 
body  of  the  uterus,  whether  carcinoma  or  sarcoma,  presents  a  discharge  while  the 
infiltration  is  still  in  an  early  stage — that  is,  before  it  has  gone  beyond  the  reach  of 
radical  operation. 

"In  forming  a  conclusion  as  to  whether  or  not  a  lesion  is  malignant,  we  should 
not  give  too  much  weight  to  the  j'outh  of  the  patient.  To  be  sure,  in  carcinoma 
the  patient  is  usually  past  thirty-five.  But  carcinoma  may  occur  before  thirty. 
One  patient  for  whom  I  did  an  abdominal  hysterectomy  for  carcinoma  w^as  but 
twenty-eight  and  the  disease  had  then  been  present  long  enough  to  form  a  large 
mass  and  had  been  gi\'ing  her  much  trouble  for  several  months.  Several  cases 
of  this  disease  in  patients  under  twenty  have  been  reported.  Sarcoma  may  de- 
velop at  any  age. 

"Called  to  see  a  patient  with  pelvic  di.sea.se,  if  there  is  no  erasion  or  ulceration 
of  the  cervix,  no  induration  of  the  cervix  or  body  of  the  uterus,  and  no  chronic 
pathological  discharge,  we  are  safe  in  assuming  that  the  uterus  is  free  from  malig- 
nant trouble.  When  any  of  these  signs  are  present  we  must  make  a  differential 
diagnosis. 

*  Early  Recognition  of  Uterine  Cancer.  II.  S.  Crossen,  M.  D.  St.  Ix)uis  Courier  of  Medi- 
cine, 1900. 


DIFIERENTIAI.   DIAGNOSIS  OF  MALIGNANT   DISEASE  669 

Induration  in  the  Cervix. 

"Induration  in  the  cervix  may  be  due  to  cystic  disease  or  to  scar-tissue  from 
laceration  or  to  a  fibroid  or  to  malignant  disease. 

In  cystic  disease,  if  the  nodule  be  punctured  and  then  pressed  upon  the  char- 
acteristic clear  glairy  substance  will  be  extruded  anfl  the  induration  will  largely 
disappear.  If  there  remains  enough  induration  to  make  the  diagno.sis  doubtful, 
excise  a  small  wedge-shaped  piece  and  submit  it  to  a  pathologist  for  examination. 

"In  scar=tissue  from  laceration,  the  induration  is  limited  to  the  site  of  injury 
and  the  cause  is  plain.  Also  in,  scar-tissue  the  area  of  induration  remains  practically 
the  same,  whereas  if  malignant  the  area  of  induration  gradually  increases.  In  this 
case,  as  in  every  other,  if  there  is  reasonable  doubt  after  a  short  period  of  careful 
observation,  excise  a  piece  for  microscopic  examination. 

''In  fibromyoma  of  the  cervix,  fibroids  elsewhere  in  the  uterus  may  often  be  de- 
tected, making  it  probable  that  the  nodule  in  the  cervix  is  similar  in  nature.  A 
well-marked  tumor  of  the  cervix,  even  a  fibromyoma,  should  be  removed,  for 
almost  without  exception  a  fibroid  in  that  situation  causes  very  troublesome 
symptoms.  A  small  mass  with  no  fibroids  elsewhere  should  have  a  piece  excised 
to  make  certain  the  diagnosis. 

Ulcer  or  Erosion  on  Cervix. 

"An  ulcer  or  a  spot  of  erosion  on  the  cervix  may  be  due  to  an  irritating  discharge, 
to  a  pessary  or  other  irritant,  to  eversion  of  the  mucous  membrane  by  laceration, 
or  to  tuberculosis,  syphiUs,  chancroid  or  cancer.  In  the  first  two  mentioned  the 
lesion  heals  promptly  on  removing  the  cause. 

"Where  the  cervix  is  torn  so  deeply  that  the  mucous  membrane  is  everted  and 
gi-anulating,  the  cervix  should  be  repaired,  and  the  tissue  removed  in  the  denuda- 
tion for  repair  may  be  examined  microscopically.  If  there  is  no  malignant 
trouble,  the  cervix  ^^•ill  be  in  much  better  condition  than  before,  and  we  will  have 
satisfied  ourselves  that  it  ..as  only  simple  trouble  and  the  patient  need  never  know 
that  there  was  a  suspicion  of  malignancy.  If  malignant  infiltration  is  found  in 
the  excised  tissue  the  uterus  can  be  removed  at  once  with  the  probability  of  a 
permanent  cure. 

"Tubercular  ulceration  of  the  cervix  is  rare.  The  diagnosis  is  made  from  micro- 
scopic examination  of  pus  and  scrapings  from  the  diseased  area. 

"In  syphilitic  ulceration  there  are  usually  other  lesions  or  a  history  which  makes 
the  diagnosis  clear.  Furthermore,  a  syphilitic  lesion  of  the  cervix,  whether  pri- 
mary, secondary  or  tertiary,  should  yield  within  a  reasonable  time  to  appropriate 
treatment,  provided  the  patient's  general  health  is  not  too  much  depressed. 

"Chancroidal  ulceration,  which  is  thoroughly  causterized,  should  within  a  short 
time  thereafter  show  healthy  granulation  and  rapid  healing.  A  sore  on  the  cervix 
that  resists  appropriate  treatment  should  have  a  piece  removed  for  examination. 

"The  following  method  of  differential  diagnosis  has  been  proposed:  Soak  a 
pledget  of  cotton  in  10  per  cent  copper  sulphate  solution  and  apply  it,  for  a 
minute  or  two,  to  the  suspicious  surface.     If  the  lesion  is   a  simple    erosion,  a 


670  MALIGNANT  DISEASE  OF  THE  UTERUS 

bluish-white  coating  will  form  without  hemorrhage.  By  repeating  the  application 
at  intervals  of  three  or  four  days  the  erosion  will  soon  be  healed.  If  the  lesion 
is  an  ectropion  it  will  be  blanched  by  the  appUcation.  If  the  lesion  is  cancer- 
ous ulceration,  the  copper  sulphate  application  will  cause  bleeding.  A  few  days 
later  another  apphcation  is  made,  and  if  the  bleeding  is  more  free  the  diagnosis 
of  incipient  carcinoma  is  almost  certainly  correct.  Heitzman,  who  brings  for- 
ward this  method,  states  that  he  rarely  failed  to  find  microscopic  confirmation 
of  this  provisional  diagnosis.  In  all  ulcerations  except  malignant,  the  bleeding  is 
checked  by  the  copper  sulphate  of  solution  in  a  few  applications,  and  the  persist- 
ence of  a  single  bleeding  point  after  the  rest  of  the  raw  surface  is  healed  in- 
dicates malignancy  and  calls  for  a  microscopic  examination  of  tissue  from  the 
suspected  area. 

Discharge  From  the  Uterus. 

''There  still  remain  for  differential  diagnosis  the  diseases  causing  uterine  dis- 
charge, and  here  is  where  the  difficulties  begin  and  where  there  have  been  so  many 
failures.  I  say  'many  failures, '  for  of  the  hundreds  of  women  who  die  annually 
of  cancer  of  the  uterus,  I  believe  a  large  number  go  to  physicians  in  the  early 
stages  and  are  treated  for  chronic  endometritis. 

"Taking  up  the  differential  diagnosis,  we  know  that  malignant  disease  is  always 
chronic.  So  we  can  eliminate  at  once  all  the  acute  diseases,  leaving  only  the 
following:  Chronic  endocervicitis  (septic,  gonorrhoeal  and  glandular),  chronic 
ENDOMETRITIS  (simple,  septic,  gonorrhoeal  and  tubercular),  Polypi  and  fibromy- 
omata. 

"In  differentiating  these  affections  from  malignant  trouble  the  effect  of  treat- 
ment is  an  important  item.  Inflammation  of  the  uterus  in  any  form  is  gTeatly 
benefited  by  appropriate  treatment.  Consequently  every  case  of  uterine  dis- 
ease presenting  induration,  ulceration,  or  discharge,  should  be  subjected  to 
careful  and  vigorous  treatment  for  the  purpose  of  differential  diagnosis  as  well 
as  for  the  purpose  of  effecting  a  cure. 

"Chronic  Endocervicitis.  In  suspected  chronic  endocervicitis,  a  very  good  plan 
is  to  give  a  hot  antiseptic  douche  two  or  three  times  daily,  and  every  second  or 
third  day  apply  a  4  per  cent  silver  nitrate  solution,  or  tincture  of  iodine,  to  the 
cervical  canal.  If  there  is  a  marked  congestion  of  the  cervix,  make  multiple 
punctures.  If  the  external  os  is  so  small  as  to  interfere  with  drainage,  open  it 
by  dilatation  or  incision.  If  there  are  cysts,  puncture  and  evacuate  them  and 
touch  the  cavities  with  silver  nitrate  or  tincture  of  iodine  or  carbolic  acid.  If 
there  are  polypi,  remove  them.  If  the  cervix  is  hypertrophied  and  riddled  with 
cyst,  excise  most  of  the  diseased  area  and  repair  the  cervix  or  partially  amputate 
it.  • 

''Any  tissue  removed  from  the  cervix,  either  curetings  or  polypi  or  pieces  removed 
in  denudation  for  repair,  should  ])0  subjected  to  a  microscopic  examination  in 
every  case  that  is  tlie  least  suspicious.  The  simple  fact  that  cystic  disease  is  present 
do(iS  not  exclude  cancer.  Both  may  be  present,  and  if  the  pathological  discharge 
persists  after  a  course  of  treatment,  a  piece  should  be  excised  from  the  suspicious 
area. 


DIFFERENTIAL  DIACNOSIS  OF  MALIGNANT  DISEASE  071 

"Chronic  Endometritis.  Simple  eudonietiitis — t  luit  is,  where  there  is  no  pus  in- 
fection— is  due  usually  to  poor  blood  or  a  nuilposition  or  a  stenosis  or  subinvolution 
or  a  tumor.  Remove  the  cause  and,  if  the  changes  in  the  endometrium  are  not 
marked,  they  will  subside  spontaneously  or  after  a  few  astringent  applications. 
If  the  pathological  changes  are  marked,  it  is  not  sufficient  to  remove  the  cause 
but  we  must  remove  also  the  diseased  endometrium,  that  a  new  and  better  one 
may  develop  under  the  bettered  conditions.  If  the  case  is  not  perfectly  plain, 
the  scrapings  should  be  examined  microscopically  that  the  diagnosis  may  be  con- 
firmed or  disproved. 

"In  chronic  septic  endometritis  and  in  chronic  gonorrhoeal  endometritis,  the  idea 
of  effecting  a  cure  by  long-continued  intra-uterine  applications,  repeated  week 
after  week  and  month  after  month,  is  a  delusion  and  a  snare.  These  long-con- 
tinued applications  rarely,  if  ever  effect  a  cure,  they  frequently  cause  extension 
of  the  inflammation  to  the  tubes,  and  worse  still,  they  deceive  the  patient  and 
the  physician  with  the  thought  that  something  is  being  done  towards  a  cure — 
whereas,  little  or  no  real  progress  is  made  against  inflammation,  and  if  malignant 
disease  be  present  it  is  allowed  to  develop  till  it  is  past  cure. 

"  In  all  these  cases  in  which  the  trouble  persists  after  a  course  of  treatment  in- 
cluding a  few  intra-uterine  applications,  the  uterus  should  be  carefully  cleared  out 
with  a  curet.  Then  if  the  trouble  is  only  inflammation,  the  patient  is  in  a  fair 
way  to  get  well,  and  if  the  microscopic  examination  of  the  scrapings  shows  malig- 
nant disease,  the  uterus  can  be  removed  in  this  early  stage  with  a  well-founded 
hope  of  saving  the  patient's  Kfe. 

"  Fibromyomata  are  frequently  multiple,  and  when  only  a  single  tumor  can  be 
felt  it  may  be  of  such  large  size  or  have  existed  so  long  with  but  little  disturbance, 
that  malignancy  is  excluded.  But  there  are  many  cases  in  which  the  mass  is 
small  and  as  far  as  known  has  existed  only  a  short  time.  In  these  cases  the  most 
important  point  in  the  differential  diagnosis  is  the  change  that  takes  place  in  the 
endometrium  in  the  two  diseases. 

"  A  fibromyoma  frequently  causes  a  chronic  hypertrophic  endometritis  which 
gives  rise  to  discharge  and  hemorrhage. 

"  A  malignant  tumor  starting  deep  in  the  uterine  wall  may  at  first  cause  similar 
changes,  but  in  the  course  of  time  and  before  it  reaches  a  large  size  or  passes  beyond 
the  limit  of  complete  removal,  it  extends  to  the  endometrium,  and  characteristic 
elements  will  be  found  in  the  uterine  scrapings.  Furthermore,  the  gi-eat  majority 
of  malignant  growths  of  the  body  of  the  uterus  begin  in  the  endometrium  and  so 
produce  characteristic  changes  there  in  the  very  earliest  stage. 

"  Therefore,  in  a  case  of  small  tumor  of  doubtful  character,  accompanied  with 
discharge  or  bleeding,  curetment  is  advisable  as  a  means  of  diagnosis.  If  the 
uterine  scrapings  do  not  show  malignant  infiltration  we  are  justified  in  assuming 
that  the  tumor  is  a  fibroid,  but  if  the  scrapings  do  show  malignant  infiltration  the 
radical  operation  is,  of  course,  indicated  at  once. 

"  Another  point  which  should  be  kept  in  mind  is  that  a  malignant  tumor  which 
at  first  causes  disturbance  of  the  endometrium  by  pressure  or  proximity  only, 
may  later  send  its  characteristic  elements  to  the  endometrium  where  they  csm  be 
reached  with  the  curet.     Consequently,  when  the  first  examination  shows  nothing 


672  MALIGNANT  DISEASE  OF  THE  UTERUS 

malignant,  if  signs  of  marked  endometrial  disturbance  again  appear,  the  dis- 
eased tissue  should  again  be  removed  for  examination. 

"  In  the  later  stages  also  of  uterine  tumors,  curetment  is  valuable  as  a  diag- 
nostic means.  For  instance,  a  patient  presents  a  large  tumor  of  the  uterus  of 
doubtful  character,  with  pain  and  discharge  and  marked  disturbance  of  the 
general  health.  Curetment  will  lessen  the  hemon-hage  and  discharge  temporarily 
and  will  furnish  tissue  for  examination.  If  the  scrapings  show  no  malignant 
infiltration,  the  tumor  is  probably  a  fibroid  and  removal  may  be  indicated.  If 
the  scrapings  do  show  malignant  trouble,  only  palliative  measures  are  indicated, 
as  the  gro^^•th  has  advanced  too  far  for  complete  removal. 

"There  remains  still  unmentioned  the  one  form  of  malignant  disease  that  is  most 
difficult  of  positive  diagnosis.  I  refer  to  a  malignant  tumor  growing  in  a  fibroid 
or  resulting  from  the  degeneration  of  the  same.  In  a  number  of  well-authenti- 
cated cases,  malignant  tissue  has  been  found  in  tumors  that  were  undoubtedly 
for  several  years  simple  fibroids.  Fibrocystic  tumors  seem  more  dangerous  in 
this  respect  than  the  solid  tumors.  The  cases  are  not  very  frequent  but  they 
do  occur,  and  a  fibroid  that  takes  on  rapid  growth  at  any  time  near  the  meno- 
pause is  open  to  this  suspicion.  As  the  malignant  infiltration  is  for  a  long  time 
confined  within  the  fibroid,  it  does  not  reach  the  uterine  canal,  and  a  positive  diag- 
nosis can  be  made  only  by  removal  of  the  tumor." 

In  the  later  stages  of  carcinoma  the  pressure  symptoms  and  other  complications 
mentioned  under  pathology,  develop  and  cause  the  patient  much  suffering.  Can- 
cerous CACHENiA  (a  yellowish  anemic  color  with  emaciation,  due  to  deterioration 
of  the  blood)  appears,  and  also  a  foul  discharge  and  persistent  bleeding. 
If  the  cervix  is  involved,  a  fungating  mass  may  be  felt  in  the  vagina. 

In  the  differential  diagnosis  of  cancer,  I  have  purposely  avoided  giving  promi- 
nence to  these  symptoms,  for  they  represent  a  late  stage  of  the  disease.  The 
diagnosis  should  be  made  before  such  symptoms  develop,  if  the  patient  conies 
under  observation  in  time. 

In  working  for  general  early  diagnosis  of  cancer  of  the  uterus,  we  meet  with  one 
very  serious  difficulty  which,  probably  more  than  any  other,  is  responsible  for 
the  many  deaths  from  this  disease.  I  refer  to  the  want  of  knowledge  on  the  part 
of  the  public  generally,  as  to  the  serious  import  of  irregular  blood-tinged  vaginal 
discharges  in  women  approaching  the  menopause.  A  very  large  proportion  of 
patients  with  cancer  of  the  uterus  do  not  consult  a  phj^sician  until  the  malignant 
infiltration  has  advanced  bej'ond  cure.  The  disturbance  in  the  early  stage  is  so 
slight  (just  a  slight  leucorrhoea  streaked  with  blood  occasionally)  that  the  patient 
thinks  it  of  no  particular  significance  and  neglects  to  have  any  investigation  until 
too  late. 

Whenever  an  occasional  streak  of  blood  or  spot  of  blood  appears  in  a  leucorrhoeal 
discharge,  particularly  in  a  woman  approaching  forty  or  older,  an  examination  is 
urgently  required,  in  order  to  determine  certainly  whether  or  not  there  is  beginning 
cancer  in  the  cervix  or  body  of  the  uterus.  Such  women  should  seek  medical 
advice  at  once,  that  the  cause  of  the  blood-streak  may  be  determined  without 
delay.  Education  of  the  public  in  this  matter  is  urgently  needed  and  if  carried 
on  patiently  and  persistently  and  judiciously,  will  save  thousands  of  women  from 


TREATMENT  OF  CARCINOMA  OF  CERVIX  673 

death  by  uterine  cancer.  However,  as  I  remarked  when  speaking  on  this  subject 
two  years  ago,*  "The  education  of  the  pubUc  in  this  matter  is  an  exceedingly 
luird  task.  Of  course  physicians,  as  individuals,  can  help  by  giving  information 
to  their  patients.  But  there  is  a  larger  medium  of  publicity  that  should  certainly 
be  utilized  in  some  way  in  a  matter  of  such  great  importance  to  the  public.  I 
refer  to  the  public  press  and  periodicals.  This,  however,  is  a  delicate  matter 
and  one  for  concerted  action  only  on  the  part  of  the  profession  as  a  body,  and  not 
for  individual  action.  This  phase  of  the  subject  is  being  already  considered  in 
a  practical  way  and  it  is  hoped  that  at  the  next  meeting  of  the  American  Medical 
Association  the  matter  will  be  thoroughly  discussed  and  some  definite  and  effective 
steps  taken  for  the  general  dissemination  of  this  much-needed  information." 

The  Reportf  of  the  special  committee  appointed  by  the  American  Medical 
Association  to  consider  this  matter  should  be  read  by  every  physician,  and  the 
information  contained  therein  should  be  disseminated  in  every  practicable  way. 

That  much  good  can  be  accomplished  by  a  systematic  and  sustained  fight  in 
this  direction  is  shown  by  the  results  in  East  Prussia. 

Winter,  aided  by  the  professional,  sociologic  and  governmental  conditions  there 
existing,  carried  on  a  most  successful  campaign  against  this  disease.  The  report 
of  the  first  year's  work  showed,  among  other  things:  (a)  that  the  proportion  of 
carcinoma  patients  who  consulted  a  physician  within  three  months  after  the  ap- 
pearance of  symptoms,  was  raised  from  32  per  cent  to  57  per  cent;  (b)  that  the 
proportion  of  patients  operated  on  within  two  weeks  after  the  first  consultation, 
increased  from  78  per  cent  to  90  per  cent;  and  (c)  that  the  operabihty  in  patients 
seeking  treatment  was  raised  from  62  per  cent  to  74  per  cent. 

TREATMENT 

For  purposes  of  treatment,  the  cases  of  carcinoma  of  the  cervix  are  divided 
into  two  classes — operable  and  inoperable. 

OPERABLE  CASES. 

This  class  comprises,  theoretically,  those  cases  in  which  the  mahgnant  disease 
is  still  limited  to  tissues  that  admit  of  complete  removal.  Practically,  it  comprises 
those  cases  in  which  there  is  a  chance,  even  a  small  chance,  that  the  carcinoma 
is  limited  to  the  tissues  mentioned  and  in  which  the  patient  is  in  condition,  or 
can  be  put  in  condition,  to  stand  the  radical  operation  with  reasonable  safety. 
By  "radical  operation"  I  do  not  refer  to  any  particular  form  of  operation,  but 
to  any  operation  that  removes  all  the  tissues  likely  to  be  involved  in  that  partic- 
ular case. 

As  to  what  tissues  may  be  removed,  by  those  skilled  in  pelvic  work,  that  is  well 
known.  The  removal  of  the  uterus  is  the  least  that  is  to  be  done.  In  selected 
cases,  the  lower  part  of  one  or  both  ureters  may  be  removed,  or  a  part  or  the 
whole  of  the  bladder,  or  a  part  or  the  whole  of  the  rectum.     Also,  the  pelvic  con- 


*  The  Promotion  of    Early  Diagnosis  in  Malignant  Disease  of   the  Uterus,  by  H.  S.  Croseen, 
M.D.   Medical  Bulletin  of  Washington  University,  1905. 

t  Journal  of  the  American   Medical  Association,  Dec.  8,  1906. 


674  Malignant  disease  of  the  uterus 

nective  tissue  generally  with  its  contained  lymphatic  vessels  and  glands,  may 
be  cleared  out  to  the  soft  structures  of  the  pelvic  wall,  and  the  enlarged  lymphatic 
glands  about  the  illiac  vessels  may  be  extirpated.  I  am  not  stating  that  any  of 
these  extreme  measures  should  be  employed  in  any  case.  I  am  only  pointing  out 
what  may  be  done  and  the  patient  still  survive,  in  selected  cases. 

The  question  as  to  the  advisability  of  such  extensive  operative  work  does  not 
turn  upon  any  question  as  to  the  possibility  of  removal  of  these  structures,  but 
upon  the  probability  that  carcinoma  cells  have  simultaneously  extended  to  other 
and  inaccessible  regions.  Careful  investigations  in  this  direction  have  been  made 
and  many  extensive  operations  have  been  carried  out,  but  the  question  is  not 
yet  settled.  However,  results  so  far  have  not  been  such  as  to  encourage  operation 
in  these  extensive  cases. 

I  feel  that  the  lesson  to  be  drawn  from  the  work  up  to  the  present  time,  is  that 
ordinarily  recurrence  is  practically  certain  when  the  carcinomatous  infiltration 
has  extended  so  that  it  involves  the  bladder  or  the  rectum  or  the  outlaying  lymph- 
atic glands  or  the  connective  tissue  around  the  ureters.  When  any  of  these  struc- 
tures are  evidently  involved,  it  is  almost  certain  that  there  are  scattered  carcinoma 
cells  in  adjacent  deeper  and  inaccessible  tissues,  hence  these  cases  lie  outside  the 
operable  class.  There  are  exceptional  cases,  for  example,  of  distinctly  localized 
involvement  in  a  slow-growing  tumor,  where  it  may  be  advisable  to  excise  a 
portion  of  the  bladder  or  ureter.  But  for  the  present,  I  feel  that,  ordinarily,  to 
subject  such  a  patient  to  an  attempted  radical  operation  is  to  cause  her  to  pass 
through  the  dangers  and  the  suffering  of  one  of  the  most  serious  operations  in 
surgery,  without  any  reasonable  hope  of  cure.  If  hysterectomy  as  a  palliative 
measure,  is  desired,  that  is  an  entirely  different  proposition,  and  is  carried  out  in 
a  less  extensive  and  less  dangerous  way. 

In  order  to  get  a  clear  understanding  as  to  the  limit  of  the  operable  class,  it  is 
well  to  divide  the  course  of  carcinoma  of  the  cervix  into  three  stages.  In  the 
first  stage  the  disease  is  confined  entirely  to  the  uterus.  Removal  of  the  uterus 
will  remove  the  entire  process  and  effect  a  permanent  cure.  In  the  second  stage 
the  carcinoma  cells  have  gotten  outside  the  uterus  into  the  parametrium  for  a 
short  distance — but  still  not  beyond  the  reach  of  operation,  provided  the  opera- 
tion includes  a  wide  removal  of  the  connective  tissue  beside  the  uterus.  In  the 
THIRD  stage  there  is  evident  involvement  of  the  ureters  or  of  the  outlying  con- 
nective tissue  or  of  the  bladder  or  of  the  rectum  (with  less  evident  involvement 
of  deeper  and  inaccessible  tissues),  making  complete  removal  of  all  involved 
tissue  impossible. 

The  cases  belonging  to  the  first  and  second  stages  are  operable  as  a  general 
proposition.     The. cases  in  the  third  stage  are  inoperable. 

How  to  Determine  Operability. 

How  extensive  is  the  carcinomatous  infiltration — has  it  reached  the  third 
stage?  That  is  the  important  question,  for  the  answer  determines  whether  or 
not  the  patient  is  to  be  subjected  to  radical  operation. 


TREATMENT  OF  (;Anf'[.VOMA  OF  CERVIX  675 

To  determine  this  absolutel}-  in  any  case  is  impossible.  It  may,  however,  be 
determined  approximately. 

The  signs  upon  which  we  must  depend  largely  for  determining  it  are  the  in- 
duration (occasioned  by  the  infiltration  of  the  tissues  with  carcinoma  cells  and 
opposing  round  cells)  and  the  fixation  of  the  uterus,  which  is  present  when  the 
infiltration  extends  out  to  the  pelvic  wall. 

Uterus  Movable.     If  the  uterus  is  freely  movable  operation  is  indicated. 

Uterus  Fixed.  When  the  uterus  is  not  movable,  it  is  then  necessary  to  deter- 
mine whether  the  fixation  of  the  organ  is  due  to  malignant  infiltration  or  to 
inflammatory  infiltration.  If  the  fixation  is  due  to  malignant  infiltration,  opera- 
tion is  not  indicated — the  case  has  already  passed  into  the  third  stage  and  pallia- 
tive measures  only  are  permissible.  If  the  fixation  is  due  to  inflammatory 
infiltration,  it  is  not  a  bar  to  operation. 

The  infiltration  is  probably  carcinomatous  if  it  is  in  the  lower  part  of  the  broad 
ligament  and  directly  continuous  with  the  carcinomatous  area  of  the  cervix,  if 
it  is  not  tender  and  if  there  is  no  history  of  recent  inflammatory  trouble  and  no 
evidence  of  the  same  in  the  pelvis. 

The  inflammation  is  probably  only  inflammatory  if  there  is  a  mass  about  one  or 
both  tubes  (salpingitis),  if  the  infiltration  of  the  broad  ligament  is  mostly  in  the 
upper  part,  if  the  bladder  and  rectal  walls  are  not  involved  and  if  the  patient 
gives  a  long  history  of  inflammatory  trouble  and  short  history  of  cancer.  In  such 
a  case,  radical  operation  is  indicated. 

In  order  to  determine  approximately  the  amount  of  fixation  and  its  probable 
character,  it  is  often  necessary  in  a  doubtful  case  to  employ  examination  under 
anesthesia,  that  deep  palpation  of  all  parts  of  the  pelvis  may  be  made.  In  such 
a  case  a  deep  recto-abdominal  palpation  of  all  the  intra-pelvic  structures,  as  well 
as  the  vagino-abdominal  palpation,  is  usually  advisable. 

This  examination,  upon  which  the  question  of  operation  turns,  is  a  very  im- 
portant procedure  and  requires  much  skill  and  much  experience  with  this  class 
of  eases.  If  after  a  thorough  examination,  there  is  reasonable  doubt  as  to  the 
inoperability  of  the  case,  operation  is  indicated,  for  the  patient  is  entitled  to  every 
chance  possible  in  this  otherwise  fatal  disease. 

In  these  doubtful  cases,  the  operation  is  begun  as  an  exploratory  abdominal 
section.  After  the  abdomen  is  opened,  the  pelvis  is  thoroughly  explored  as  to 
the  infiltration  and  thickenings  and  their  character,  and  as  to  the  presence  of 
evident  glandular  metastases.  If  this  intra-peritoneal  examination  shows  the 
tumor  to  be  an  operable  one,  the  radical  operation  is  carried  out  at  once.  If 
the  tumor  is  found  to  be  inoperable,  the  abdomen  is  closed,  with  or  without  the 
execution  of  one  of  the  palliative  measures  mentioned  later. 

Operative  Measures. 

In  the  operable  cases,  what  operation  should  be  chosen?  In  order  to  answer  this 
question  intelligently,  let  us  see  just  what  the  operation  must  accomplish.  In 
most  of  the  cases  the  disease  has  passed  the  first  stage  before  the  patient  con- 
sults a  physician.     There  is  already  carcinomatous  infiltration  of  the  connective 

44 


676  MALIGNANT  DISEASE  OF  THE  UTERUS 

tissue  near  the  uterus — not  sufficient,  perhaps,  to  be  appreciable  to  the  examining 
finger,  but  amply  sufficient  to  cause  recun-ence.  This  infiltration  of  the  para- 
metrium in  practically  all  cases  that  come  to  operation,  is  the  cause  of  the  lament- 
able failure  of  the  old  vaginal  hysterectomy  and  the  old  abdominal  hysterectomy 
as  a  cure  for  cancer  of  the  cervix  uteri.  Occasionally  a  case  was  met  with  in  the 
first  stage  (simply  a  small  ulcer  on  the  vaginal  portion  of  the  cervix  or  a  small 
nodule  in  the  interior  of  the  cervix),  and  in  these  cases  the  ordinary  vaginal  or 
abdominal  hysterectomy  removed  all  the  involved  tissue  and  resulted  in  cure. 
However,  the  general  effect  of  these  occasional  good  results  was  detrimental 
rather  than  otherwise,  for  they  prolonged  the  reliance  on  these  inadequate  opera- 
tions for  the  cure  of  the  disease  and  postponed  the  devising  of  more  effective 
operative  measures. 

When  physicians  began,  after  the  lapse  of  some  years,  to  count  up  the  perma- 
nent cures  from  the  operations  mentioned,  the  results  were  most  discouraging 
and  disheartening.  It  was  found  that  five  per  cent  of  cures  was  all  that  could  be 
reasonably  claimed.  Some  operators  who  had  had  many  cases  could  not  present 
one  permanent  cure,  and  a  few  lost  all  hope  and  claimed  that  the  disease  could 
not  be  cured  by  operation. 

Careful  investigation  into  the  pathology  of  the  disease  brought  out  the  cause 
of  the  failure  of  the  operative  measures  then  in  vogue,  and  also  pointed  out  the  way 
to  the  methods  which  have  proved  successful  and  are  proving  more  and  more 
successful  as  they  are  used  more  and  more  in  the  early  stage  of  the  disease. 

The  cause  of  the  failure  of  the  former  methods  was  found  to  be  due  to  the  ex- 
tension of  carcinoma  cells  into  the  parametrium  in  practically  all  cases  when  the 
patient  comes  for  operation.  It  follows  then  logically  and  has  been  thoroughly 
established  by  extensive  experience,  that  any  operation  that  is  to  be  used  with 
a  reasonable  hope  of  success  in  carcinoma  of  cervix,  must  remove  this  infiltrated 
parametrium. 

Any  operation  in  which  the  line  of  excision  lies  close  to  the  uterus,  as  in  the  old 
vaginal  and  abdominal  hysterectomy  for  cancer,  can  not  be  successful  except  in 
certain  rare  cases  where  the  disease  is  just  beginning. 

Jacobs,  in  82  vaginal  hysterectomies,  saw  recurrence  in  every  one.  Some 
series  by  the  old  vaginal  or  abdominal  hysterectomy,  show  a  few  recoveries,  past 
the  five  year  limit — but  they  are  very  few  and  far  between.  McMonigle  reported 
481  hysterectomies  for  cancer  of  the  uterus,  with  479  deaths  from  recurrence  or 
from  the  operation. 

Russel  investigated  the  after  condition  of  48  cases  of  vaginal  hysterectomy 
for  cancer  of  the  cervix,  and  found  that  almost  invariably  there  was  recurrence 
at  the  site  of  the  scar,  and  not  in  the  region  of  the  lymphatic  glands. 

Another  important  point  in  regard  to  the  operation  is  that  if  transplantation 
METASTASES  are  to  be  certainly  avoided,  the  iufiltration-area  must  not  be  cut  into 
at  any  step  of  the  operation — that  is,  it  is  not  advisable  to  take  out  the  uterus 
and  then  the  infiltrated  tissues  around  the  uterus,  but  the  whole  infiltrated  area, 
including  uterus  and  parametrium,  should  be  removed  as  one  mass,  the  line  of 
excision  being  everywhere  placed  in  healthy  tissue.  When  an  incision  is  made 
through  infiltrated  tissue,  cancer  cells  are  liable  to  be  canied  into  healthy  tissue, 


TREATMENT  OF  CARCINOMA  OF  CERVIX 


677 


where  they  maj^  gi'ow.  This  has  happened  in  several  reported  cases.  Where  an 
incision  must  be  made  through  infiltrated  tissue,  it  is  safer  to  make  it  with  the 
(.•auter}'',  as  that  destroys  all  cells  with  which  it  comes  in  contact. 

It  must  be  kept  in  mind  also  that  it  is  impossible  to  be  certain  in  any  case  that 
the  parametrium  is  not  involved,  no  matter  how  early  the  case  nor  how  perfectly 
normal  the  parametrium  feels.  Sampson  has  demonstrated  conclusively  that 
in  some  cases  the  carcinoma  sends  out,  by  direct  growth,  very  fine  prolongations 
into  the  parametrium  and,  in  other  cases,  the  carcinoma  cells  make  short  excur- 
sions into  the  lymph  spaces  of  the  parametrium.  In  such  cases,  there  is  no 
change  in  the  parametrium  appreciable  to  the  examining  finger. 

It  is  evident  then  that  any  operation,  whether  vaginal  or  abdominal,  that  does 
not  remove  the  parametrium,  is  not  admissible  as  an  operation  for  the  cure  of  car- 
cinoma of  the  cervix,  except  in  certain  rare  cases. 


Fig.  622.  The  Essentials  for  any  Radical  Operation  for  Cancer  of  the  Cer\-ix  Uteri.  The  excision  of  structures 
as  here  indicated  must  be  carried  out,  whether  the  operation  be  abdominal  or  vaginal.  (Kelly — Operative 
Gynecology .) 


Any  operation,  whether  vaginal  or  abdominal,  that  does  remove  the  parametrium, 
is  admissable  in  that  it  fulfills  one  of  the  essential  requirements.  Whether  the 
work  is  done  by  way  of  the  vagina  or  by  way  of  the  abdomen,  is  a  matter  of  sec- 
ondary importance.     The  essentials  of  the  operation  are  shown  in  Fig.  622. 

One  point  to  be  kept  in  mind  is  the  removal  of  the  uterus  and  parametrium 
intact.  The  broad  ligament,  including  the  tubes  and  ovaries,  should  of  course  be 
removed.  It  is  in  the  lower  part  of  the  broad  ligament,  however,  that  the  infiltra- 
tion extends  the  farthest  and  that  the  principal  operative  difficulties  are  met 
with. 

I  prefer  the  abdominal   route    as  a  rule  in  operating  for  cancer  of  the  cervix, 


678  MALIGNANT  DISEASE  OF  THE  UTERUS 

but  I  have  no  serious  objection  to  the  vaginal  operation  when  it  includes  the 
technique  required  for  the  removal  of  the  parametrium.  It  will  hardly  be  neces- 
sary for  me  to  take  up  the  advantages  and  disadvantages  of  the  various  opera- 
tions proposed  for  this  disease.  I  think  it  ^^Tll  be  well,  however,  to  give  an  idea 
of  what  removal  of  the  parametrium  means.  A  brief  description  of  certain  points 
of  any  one  of  the  really  radical  operations  will  do  this. 

One  of  the  best  of  the  abdominal  operations  is  that  elaborated  b}^  Wertheim. 
The  essential  steps  are  given  in  the  followdng  quotation  from  the  report  of  a  case 
upon  which  I  operated  in  1903  .'^  The  patient  was  33  years  of  age,  the  mother  of 
five  children  and  in  good  general  health.  The  first  symptom  (some  leucorrhoea, 
with  prolonged  menstrual  flow)  xv&s  noticed  just  eight  months  before  the  opera- 
tion. Two  months  later  a  blood-streaked  intermenstrual  discharge  began.  The 
bleeding  increased,  pains  and  weakness  came  on  and  finally  the  patient,  emaciated 
and  weak  from  loss  of  blood,  consulted  Dr.  H.  H.  Meyer,  to  see  if  there  was  any 
serious  trouble.  He  examined  her,  made  the  diagnosis  and  referred  her  to  me 
for  operation. 

"Examination  revealed  a  large  bleeding  mass  springing  from  the  cervix  and 
filhng  the  upper  part  of  the  vagina.  The  mass  was  the  size  of  a  small  fist  and  so 
obstructed  the  upper  part  of  the  vagina  that  it  was  impossible  to  make  a  satisfactory 
examination  of  the  uterus  and  surrounding  tissues.  I  advised  that  the  patient 
submit  to  examination  under  anesthesia,  when  the  obstructing  mass  could  be 
cleared  away  and  the  extent  of  the  parametria!  involvement  approximately  de- 
termined. 

"Under  anesthesia  it  was  found,  after  the  projecting  tumor-mass  had  been  re- 
moved, that  the  whole  cervix  was  involved  and  that  the  growth  extended  a  short 
distance  along  the  anterior  vaginal  v/all.  There  was  apparently  some  infiltration 
of  the  parametrium,  particularly  in  the  left  side,  but  still  the  uterus  was  freely 
movable. 

"It  was  a  case  for  radical  operation,  ^\■ith  a  fair  chance  of  removing  all  of  the 
involved  tissue. 

"A  few  days  later  I  removed  the  uterus  and  parametrium  by  the  Wertheim 
method.     The  steps  in  the  operation  were  as  follows: 

"1.  After  the  usual  preparation  for  abdominal  section,  including  saturation  of 
the  patient  with  fluid  by  giving  her  all  the  water  she  would  take  in  small  quantities 
at  short  intervals  for  two  days  before  operation,  the  patient  was  anesthetized 
(ether)  and  placed  in  extreme  Trendelenburg  posture,  the  body  being  raised  to 
an  angel  of  almost  45  degi*ees. 

"2.  The  abdominal  cavity  was  opened  and  the  incision  enlarged  until  it  extended 
from  the  umbilicus  to  just  above  the  pubic  joint.  The  fundus  uteri  was  then  seized 
A\ith  a  heavy  traction  forceps  and  the  organ  drawn  strongly  upward  and  forward. 

"3.  The  left  side  of  the  abdominal  incision  was  then  retracted,  the  small  intestine 
and  the  sigmoid  flexure  were  held  out  of  the  way  and  an  incision  was  made  in  the 
peritoneum  a  trifle  below  the  point  A\here  the  left  ureter  enters  the  true  pelvis. 


*The  Wertheim  Operation  for  Cancer  of  the  Uterus;  Report  of  a   Case,   by  H.  S.  Crossen, 
M.D.   St.  Louis  Medical  Review,  June,  1903. 


TREATMENT  OF  CARCINOMA  OF  CERVIX  679 

"The  ureter  was  easily  found  and  the  incision  in  the  peritoneum  over  it  was 
continued  down  along  the  course  of  the  ureter  to  the  point  where  it  entered  the 
broad  ligament. 

"4.  Then  a  small  silk  ligature  was  passed  from  this  incision  around  the  left 
ovarian  vessels  and  tied  and  the  ligated  structures  were  cut.  The  round  ligament 
also  was  ligated  and  cut  and  then  the  clear  peritoneum  between  the  two  liga- 
tures was  cut  through,  thus  laying  open  the  broad  ligament.  The  broad  ligament 
was  then  opened  well  down  toward  its  lower  part  and  the  few  bleeding  points 
caught  wdth  forceps. 

"5.  Steps  No.  3  and  No.  4  were  then  carried  out  on  the  right  side. 

"6.  The  peritoneum  at  the  vesico-uterine  junction  was  then  cut  across  and 
the  bladder  was  separated  from  the  uterus. 

"7.  Then  a  finger  was  passed  along  the  right  ureter  from  the  point  where  it  en- 
tered the  broad  ligament  forward  until  the  finger  appeared  in  front  of  the  liga- 
ment. In  this  maneuver  the  little  pocket  or  archway,  in  which  the  ureter  lies, 
was  distinctly  felt  and  served  as  a  guide  as  the  finger  was  forced  forward.  The 
finger,  when  through  the  ligament,  had  the  ureter  immediately  below  and  in  con- 
tact with  it,  while  above  were  the  uterine  vessels  and  the  parametrium  surround- 
ing them.  The  opening  was  then  enlarged  outward  and  the  end  of  a  ligature 
carrier  was  placed  on  the  tip  of  the  finger  and  as  the  finger  was  withdrawn  the 
ligature  carrier  was  made  to  follow  it.  The  ligature  was  then  tied  a  little  beyond 
the  ureter.  When  this  tissue  was  cut  through,  the  right  ureter  could  be  seen  all 
the  way  from  the  pelvic  brim  to  its  point  of  entrance  into  the  bladder.  The 
parametria!  tissue  lying  to  the  inner  side  of  the  ureter  and  below  it,  was  then 
dissected  away,  care  being  taken  not  to  free  the  ureter  all  the  way  around,  as  I 
wished  to  avoid  any  interference  with  its  nutrition. 

"The  same  procedure  was  then  carried  out  on  the  left  side.  In  the  left  side  an 
enlarged  lymphatic  gland,  the  size  of  a  bean,  was  found  close  to  the  uterine  artery 
and  somewhat  to  the  outer  side  of  the  ureter.  The  ligature  was,  of  course,  placed 
outside  of  this  gland. 

"8.  The  uterus  and  vagina  were  then  freed  from  the  bladder  and  rectum  and 
lateral  tissues  for  about  one-third  of  the  distance  down  the  vagina,  the  connective 
tissue  lying  beside  the  cervix  and  vagina  being  included  in  the  mass  to  be  removed. 

"9.  An  assistant  then  cleansed  the  vagina,  using  first  cotton-balls  soaked  in 
bichloride  solution  and  then  dry  gauze  repeatedly  until  the  gauze  was  no  longer 
soiled.     Then  a  small  piece  of  gauze  was  placed  against  the  cervix  and  held  there. 

"10.  From  the  abdominal  cavity  I  then  compressed  the  vagina  with  a  right- 
angled  L-forceps,  the  blades  being  appiled  just  below  the  gauze  and  well  below 
the  lowest  point  of  malignant  infiltration.  At  the  other  side  of  the  vagina  another 
L-forceps  was  applied  just  below  the  first.  Both  of  these  forceps  were  clamped 
down  hard,  thus  preventing  any  fluid  from  being  squeezed  past  them. 

"The  vagina  was  then  cut  across  below  the  forceps,  the  stump  of  the  vagina  being 
caught  temporarily  with  three  or  four  artery-forceps.  The  excised  mass,  with  the 
L-forceps  still  attached,  was  removed  from  the  abdomen.  Catgut  sutures  were 
then  applied  about  the  open  end  of  the  vagina  suflB.cient  to  stop  the  hemorrhage 
and  narrow  the  opening. 


680  MALIGNANT  DISEASE  OF  THE  UTERUS 

"11.  Search  for  enlarged  glands  was  then  made  on  each  side,  first  about  the  iliac 
vessels  and  then  forward  along  the  pelvic  wall  to  the  obturator  foramen,  but  no 
enlarged  glands  were  found. 

"12.  After  all  the  bleeding  in  the  pelvis  had  been  checked,  a  narrow  strip  of 
gauze  w^as  laid  from  each  side  of  the  pelvic  cavity  to  the  open  vagina,  the  ends 
extending  into  the  vagina.  The  peritoneum  was  closed  over  the  pelvic  cavity 
in  the  usual  way,  all  raw  surfaces  being  turned  down  and  shut  off  from  contact 
Av-ith  the  intestines.  The  abdominal  incision  was  then  closed  with  tier  sutures  of 
catgut  and  tension  sutures  of  silkworm-gut. 

"The  operation  was  necessarily  lengthy,  but  the  patient  stood  it  well.  Conva- 
lescence was  smooth  and  uneventful.  The  highest  temperature  was  100.8,  re- 
corded the  second  day  after  operation. 

"  There  was  no  bladder  paralysis,  such  as  is  sometimes  present  after  this  opera- 
tion. The  patient  was  catheterized  for  three  days.  On  the  fourth  day  she  voided 
the  urine  and  continued  to  do  so  afterward  without  disturbance. 

''Beginning  the  fifth  day,  the  gauze  strips  in  the  vagina  and  pelvis  were  pulled 
out  a  little  each  day  until  about  the  tenth  day,  when  the  remaining  portions  were 
taken  out  entirely. 

"The  specimen  removed  by  operation  was  submitted  to  Dr.  C.  Fisch  for  micro- 
scopic examination  for  the  purpose  of  determining,  as  far  as  possible,  whether 
or  not  the  malignant  infiltration  had  extended  beyond  the  line  of  incision. 

"Dr.  Fisch  reported  that  the  growth  was  an  epithelioma  and  that  '  in  all  places 
examined  the  operative  separation  has  taken  place  in  healthy  tissue.' 

"The  point  at  which  the  cancer  approached  nearest  to  the  margin  of  the  re- 
moved mass  was  in  the  median  line  anteriorly,  where  the  bladder  was  separated 
from  the  uterus. 

"During  the  operation  the  bladder  separated  from  the  uterus  without  the  least 
difficulty  and  there  was  no  indication  of  involvement  of  the  bladder  wall.  The 
enlarged  lymph  node  in  the  neighborhood  of  the  left  ureter  showed  no  cancer  ele- 
ments, but  simply  a  marked  hyperplasia.  [The  patient  is  now  (4  years  after  the 
operation)  in  good  health  and  ^vith  no  evidence  of  recurrence.] 

"As  far  as  I  know  this  is  the  first  complete  Wertheim  operation  for  St. 
Louis. 

"In  1900  Wertheim  made  his  first  report  of  this  operation-method.  The  results 
so  far  obtained  have  been  encouraging,  though  not  enough  time  has  as  yet  elapsed 
to  count  the  patients  as  cured.  Last  September,  at  the  International  Gyne- 
cological Congress  at  Rome,  Wertheim  reported  120  cases  in  which  he  had  operated 
by  this  method.  Of  the  120  patients,  24  died  from  the  operation.  In  his  first 
series  of  thirty  cases,  it'  had  been  two  and  a  half  to  four  years  since  operation.  Of 
the  eighteen  of  these  who  survived  operation,  five  were  not  heard  from,  ten  were 
in  good  health  and  in  only  three  was  there  recuiTence. 

"The  object  of  this  operation  is  wide  removal  of  the  parametrium,  and  the  points 
in  the  operation  which  seem  particularly  advantageous  are: 

"a.  Exposure  of  the  ureter  at  a  point  where  it  is  easily  found,  i.  e.,  at  the  pelvic 
brim. 

"b.  Incision  of  the  peritoneum  from  this  point,  along  the  ureter  to  the  base  of 


TREATMENT  OF  CARCINOMA  OF  CERVIX  681 

the  broad  ligament.  This  brings  nearly  all  the  pelvic  portion  of  the  ureter  into 
view  and  locates  accurately  its  point  of  entrance  into  the  broad  ligament. 

"c.  Introduction  of  the  finger  through  the  base  of  the  broad  ligament  close  along 
the  ureter.  This  allows  the  ligature  about  the  uterine  vessels  to  be  placed  well 
away  from  the  uterus,  outside  the  ureter,  with  perfect  safety  and  without  the 
delay  incident  to  catheterization  of  the  ureters. 

"d.  The  firm  clamping  of  the  vagina  below  the  gi'owth  by  two  L-forceps,  one 
Ijelow  the  other.  This  closes  the  vagina,  which  is  to  be  cut  across,  and  permits 
the  mass  to  be  removed  through  the  abdomen  ^\^thout  the  possibility  of  any  con- 
taminating fluid  l^eing  squeezed  from  the  cervix. 

"e.  All  the  work  is  done  from  the  abdomen,  largely  under  the  eye  and  without 
change  of  posture,  thus  doing  away  with  delay  from  change  of  posture  and  the 
increased  danger  of  sepsis  necessarily  attendant  on  the  'combined,'  or  vagino- 
abdominal operations. 

"The  contra-indications  to  this  operation  are: 

"1.  Obesity.  When  the  patient  is  very  stout,  the  thick  abdominal  wall  and 
the  pelvic  fat  interfere  with  the  proper  exposure  and  dissection  of  the  parts. 

"2.  Any  serious  disease  of  the  heart  or  lungs  or  kidneys  or  other  organ  that  would 
render  the  patient  probably  unable  to  stand-  a  long  abdominal  operation.  In 
some  of  such  cases  a  vaginal  hysterectomy,  including,  when  necessary,  Schu- 
chardt's  incision  beside  the  rectum, will  give  a  fair  chance  of  cure  \\dthout  unduly 
jeopardizing  the  patient's  life.  Much  judgment  as  to  choice  of  operation  is  re- 
quired in  these  cases.  A  mde  removal  of  tissue,  such  as  we  get  in  the  Wertheim 
operation,  is  much  to  be  desired.  But  in  a  poorly  conditioned  patient  this  wide 
removal  of  tissue  may  be  purchased  too  dearly.  A  fair  probability  of  complete 
removal  and  a  live  patient  is  better  than  a  greater  probability  of  complete  removal 
and  a  dead  patient. 

"3.  Cancerous  infiltration  extending  beyond  the  ureters  or  involving  the  bladder 
or  rectum.  Such  cases  I  do  not  consider  suitable  for  radical  operation.  Of 
course,  I  am  aware  that  some  operators  advise  operation  in  these  cases  and  re- 
move the  infiltrated  portions  of  the  affected  organs  (bladder  or  rectum) .  Sampson, 
of  Johns  Hopkins  University,  has  adapted  the  Wertheim  operation  to  these  cases 
by  extending  the  dissection  outside  the  ureter  and  excising  the  involved  portion 
of  the  ureter  along  with  the  main  tumor. 

"Such  extensive  operations  are  experimental  as  yet. 

"I  earnestly  hope  some  procedure  may  be  devised  that  will  be  efficient  in  these 
Bases  of  immovable  uterus. 

"But  until  more  hope  can  be  held  out  than  is  justified  by  results  up  to  the  pres- 
ent time,  I  can  not  advise  such  a  patient  to  submit  to  radical  operation. 

"There  is,  however,  one  class  of  patients  with  uterine  cancer  and  extensive  in- 
filtration, rendering  the  uterus  immovable,  in  which  I  urge  operation,  namely, 
those  patients  in  which  there  is  a  probability  or  possibility  that  the  parametria! 
infiltration  is  not  malignant,  but  simply  inflammatory.  The  broad  hgament  in- 
filtration is  more  likelv  to  be  simply  inflammatory  if  it  is  situated  in  the  upper  part 
of  the  ligament,  if  there  is  a  mass  about  one  or  both  tubes  (salpingitis)  and  if  there 
Is  a  long  history  of  inflammatory  trouble  and  a  short  history  of  cancer. 


682  MALIGNANT  DISEASE  OF  THE  UTERUS 

"4:.  Beginning  cancer  of  the  body  of  the  uterus.  Ordinarily,  in  such  cases, 
vaginal  hysterectomy  is  preferable,  because  it  is  less  dangerous,  while  at  the  same 
time  permitting  removal  of  all  tissue  likely  to  be  involved. 

"The  same  may  probably  be  said  of  certain  very  early  cases  of  cancer  of  the 
cervix,  though  that  is  still  a  mooted  point. 

"I  wish  to  thank  Dr.  F.  J.  Taussig  for  assistance  in  the  case  reported  tonight. 
Dr.  Taussig  recently  worked  with  Wertheim  and  to  him  I  am  indebted  for  the 
details  of  the  operation  as  carried  out  at  the  present  time  by  that  teacher," 

Wertheim,  at  the  time  of  his  latest  report,  made  during  his  recent  visit  to  the 
United  States,  had  operated  on  345  patients  by  this  method.  Of  the  patients 
that  survived  operation  60  per  cent  remained  free  from  recurrence  at  the  end  of 
five  years  (the  usual  time-limit  for  counting  a  cure).  The  primary  mortality  of 
the  operation,  which  in  the  first  120  cases  was  20  per  cent,  has  been  reduced  to  8 
per  cent  in  the  last  hundred.  M 

Most  careful  systematic  microscopic  examination  of  the  parametrium  and 
regional  glands  was  made  in  all  cases.  As  to  the  parametrium,  in  22.8  per  cent 
of  the  cases,  the  parametrium,  though  "soft  and  distensible,  proved  to  be  cancer- 
ous. On  the  other  hand,  in  about  14  per  cent  of  all  cases,  though  there  was  con- 
siderable infiltration,  no  carcinoma  was  found."  As  to  the  regional  glands,  they 
were  found  enlarged  and  infiltrated  with  carcinoma  cells  in  28  per  cent  of  the 
cases,  and  enlarged  from  inflammatory  hyperplasia  only,  in  30  per  cent. 

One  distinct  advantage  of  the  abdominal  operation,  is  the  better  opportunity 
it  gives  for  accurate  determination  of  the  extent  of  the  carcinomatous  involvement 
before  beginning  the  operation  proper.  After  the  abdomen  is  open,  the  pelvis 
may  be  thoroughly  explored,  and  the  advisability  of  doing  a  radical  operation 
determined  before  beginning  the  same. 

In  some  cases  that  are  apparently  well  suited  for  radical  operation,  this  intra- 
peritoneal examination  shows  that  such  an  operation  would  be  utterly  useless  and 
hat  only  palliative  measures  are  permissible.  On  the  other  hand,  in  apparently 
advanced  cases,  this  thorough  exposure  of  the  pelvic  interior  may  show  that 
much  of  the  supposed  extensive  malignant  infiltration  is  only  an  inflammatory 
mass  or  a  fibroid  or  other  non-malignant  gi'owth,  and  that  radical  operation  is 
fully  justified. 

Recurrence  after  operation.  The  frequency  of  recurrence  has  been  mentioned. 
The  facts  show  that  the  prognosis  must  in  every  case  be  very  guarded,  no  matter 
how  early  or  how  thorough  the  operation.  A  recurrence  may  be  a  local  recur- 
rence (in  or  near  the  scar  of  the  operation)  or  lympli-gland  recun-ence  (in  some  of 
the  lymph  glands  in  the  pelvis  or  lower  abdomen)  or  a  distant  metastatic  recur- 
rence (in  some  organ  to  which  cancer  cells  have  been  carried  by  the  blood-stream). 
A  local  recurrence  is  amenable  to  treatment.  The  preferable  treatment,  usually, 
is  thorough  and  wide  excision  with  the  thermo-cautery.  As  an  additional  pre- 
caution, X-ray  treatment  may  be  used  following  the  excision.  The  diagnosis  of 
recun-ence  rests  on  the  same  symptoms  and  signs  as  the  diagnosis  of  the  primary 
growth.  Lymph-gland  metastasis  is  not  amenable  to  cautery  treatment,  but 
the  pain  may  frequently  be  considerably  relieved  by  palliative  measures,  including 


TREATMENT  OF  CARCINOMA  OF  CERVIX  683 

X-ray  treatment,  electricity  as  applied  for  the  relief  of  pain,  and  the  general  and 
local  measures  for  diminishing  pelvic  congestion.  The  patient  should  be  given 
morphine  or  other  preparation  of  opium  in  sufficient  quantities  to  prevent  suffering. 

Carcinoma  Complicating  Pregnancy. 

Pregnancy  may  take  place  in  a  women  with  beginning  carcinoma  of  the  cervix 
or  carcinoma  may  develop  after  impregnation.  In  either  case  the  effect  of  the 
pregnancy  is  to  markedlj^  hasten  the  gi-owth  of  the  cancer.  Carcinoma  compli- 
cating pregnancy  is  rare,  being  found  only  three  times  in  a  collecti^'e  series  of 
54,833  labor  cases.  The  treatment  depends  on  whether  or  not  the  carcinoma  is 
operable. 

Carcinoma  operable.  When  there  is  a  fair  chance  of  cure  by  radical  operation, 
that  should  be  earned  out  at  once,  "irrespective  of  the  viability  of  the  fetus." 

Carcinoma  inoperable.  When  the  carcinoma  of  the  cervix  is  inoperable,  the 
life  of  the  child  is  the  thing  of  principal  moment,  and  the  treatment  should  be 
palliative  and  directed  toward  preserving  the  life  of  the  mother  until  the  child 
has  advanced  far  enough  to  have  good  chance  of  independent  existence.  The 
details  of  the  treatment  and  the  time  to  interfere  in  an  operative  way  must 
be  determined  by  a  careful  study  of  the  conditions  present  and  the  probable 
developments  in  each  case. 

INOPERABLE  CASES 

In  the  third  stage,  only  palliative  measures  are  permissible.  The  palliative  meas- 
ures are  as  follows: 

1.  Tonics  and  Stimulants.  Give  tonics  and  stimulants  as  indicated,  such  as 
iron,  strychnia,  etc.  Administer  sedatives  in  sufficient  c^uantity  to  give  rest — 
first  the  milder  sedatives  (such  as  bromides  and  phenacetin)  and  later  mor- 
phine. The  cases  usually  come  to  opium  in  some  form  sooner  or  later  and, 
though  it  should  be  used  only  when  necessary,  it  should  be  used  as  freely  as  re- 
quired to  relieve  the  pain  and  make  the  patient  as  comfortable  as  possible  in  her 
last  months  of  life.  Give  laxatives  as  freely  as  necessary  to  prevent  constipation 
from  the  opium.  Regular  and  thorough  bowel  movements  will  save  the  patient 
much  discomfort.  Attention  to  nourishment,  as  in  other  wasting  diseases  is  of 
course  imjDortant. 

2.  Ergot  and  other  uterine  astringents  lessen  the  amount  of  blood  in  the  uterus, 
and  in  some  cases  seem  to  diminish  the  swelling  and  pain  and  hemorrhage.  They 
are  given  the  same  as  recommended  for  bleeding  in  fibromyoma. 

3.  Douches.  Antiseptic  and  astringent  douches  constitute  an  important  part 
of  the  palliative  treatment.  Hot  bichloride  douches  (1-5000)  wash  away  the  vagi- 
nal discharge,  diminish  decomposition  in  the  vagina  and  by  the  heat  diminish 
the  pain.  These  may  be  given  one  to  four  times  daily,  depending  on  the  amount 
of  discharge.  If  the  odor  persists  in  spite  of  these  douches,  lysol  may  be  used  (two 
teaspoonfuls  to  the  quart  of  water).  This  is  usually  very  effective  in  checking 
the  odor,  but  must  be  used  sufficientl}^  often  to  keep  the  vagina  approximately 
clean,  for  the  odor  depends  on  decomposition.     Weak  formol  (1-5000  to  1-2000) 


684  MALIGNANT  DISEASE  OF  THE  UTERUS 

makes  an  excellent  douche  in   these  cases.     Begin  with  the  weaker  solution  and 
advance  to  the  stronger,  if  it  does  not  cause  smarting. 

If  there  is  a  marked  hemorrhagic  tendency,  the  astringent  douche  of  alum  and 
zinc  sulphate  (see  Formulse)  or  a  tannic  acid  douche  (see  Formulee)  is  indicated. 

4.  Applications.  On  account  of  the  discharge  or  hemorrhage,  strong  astringent 
applications  are  often  needed,  such  as  tannic  acid  and  xeroform  (half  and  half) 
or  liq.  ferri  subsulphatis.  The  uterus  is  exposed  T\dth  the  speculum  and  the  ap- 
plication made  to  the  affected  area. 

The  astringent  powders  are  effective  if  held  in  place  by  a  tampon.  Iodoform 
and  tannic  acid,  equal  parts,  held  in  place  by  a  tampon,  make  a  splendid  astringent 
dressing  for  this  purpose.  When  the  odor  is  marked,  iodoform  and  charcoal 
are  useful. 

By  means  of  the  tampon  capsules  (see  page  327),  the  desired  powder  may  be 
applied  by  the  patient  at  home  as  often  as  required  after  a  douche.  She  is  directed 
to  fill  the  top  of  the  capsule  with  the  powder  before  introducing  it. 

Formol  (25%  to  50%)  applied  as  a  cauterizing  and  hardening  agent  to  the  cancer- 
ous tissue  tends  to  check  the  bleeding  and  foul  discharge. 

Zinc  chloride  also  is  an  effective  cauterant  in  these  cases  and  has  been  long  used 
for  the  purpose. 

Many  other  cauterant  and  hardening  agents  have  been  used  from  time  to  time 
with  benefit. 

In  the  use  of  all  these  agents  care  must  be  taken  to  prevent  cauterization  of  the 
vaginal  wall.  Of  course,  these  agents  are  much  more  effective  when  used  immedi- 
ately after  a  thorough  curetting-away  of  the  broken-down  bleeding  tissue.  The 
principal  beneficial  effect  is  then  due  to  the  curetment.  But  when  the  area  is 
curetted  under  anesthesia  I  think  the  best  application  to  make  immediately  after- 
ward, is  the  actual  cautery,  as  explained  below.  The  other  applications  may  be 
used  with  l^enefit  later. 

5.  Curetment  followed  by  cauterization  of  the  affected  area,  constitutes  one  of 
the  most  beneficial  of  the  palliative  measures.  In  some  exceptional  cases  this  may 
be  carried  out  satisfactorily  without  an  anesthetic. 

Under  anesthesia,  however,  the  curetment  may  be  made  much  more  thorough,  antl 
ragged  portions  of  cervix  and  vagina  may  be  clipped  off.  The  cauterization  also 
with  the  Paquelin  or  electric-cautery,  is  made  much  more  thorough — the  walls  of 
the  cavity  being  thoroughly  charred  for  quite  a  distance  below  the  surface,  care  being 
exercised,  of  course,  not  to  cause  deep  sloughing  toward  the  liladder  or  rectum,  if 
adherent.  After  the  baking  of  the  surfaces,  the  cavity  is  packed  with  the  iodo- 
form gauze,  and  the  vagina  is  packed  with  the  same.  The  effect  of  the  curet- 
ment and  cauterization  under  anesthesia  is  much  more  marked  than  without 
anesthesia.  In  doubtful  ca.ses,  where  an  examination  under  anesthesia  is  to  be 
made  to  determine  the  advisability  of  a  radical  operation,  it  is  well  to  have  the 
things  ready  so  that  if  the  carcinoma  is  found  to  be  an  inoperable  one,  palliative 
curetment  may  be  at  once  carried  out. 

The  improvement  from  a  thorough  curetment  and  cauterization  is  usually 
marked.  The  constant  discharge  and  loss  of  blood  is  checked  temporarily  and 
tVie  patient  picks  up  considerably,  sometimes  becoming  well  enough  to  take  up 


TREATMENT  OF  CARCINOMA  OP  CERVIX  685 

work  formerly  dropped.  Repeated  cauterization,  as  indicated  by  the  recur- 
rence of  bleeding  or  foul  discliarge,  is  very  beneficial.  In  some  cases  the 
extensive  scar  tissue  formation  from  repeated  cauterization  exercises  a  remark- 
able inhi])itory  effect  on  the  cancer — checking-  its  growth  and,  in  rare  cases, 
even  causing  retrogression.  At  the  St.  Louis  meeting  of  the  American  Medical 
Association  (June,  1910)  a  number  of  cases  were  reported  in  which  this 
apparent  retrogression  was  so  marked  that  the  supposed  inoperable  carcinoma 
of  the  cervix  became,  after  repeated  cauterization,  operable  and  was  then 
removed  by  radical  operation,  with  joermanent  cure.  Wliile  such  a  result 
is  very  exceptional,  yet  the  possibility  of  its  occurrence  must  be  kept  in  mind 
and  should  encourage  careful  and  persistent  treatment. 

6.  Curetment  followed  by  acetone  applications  has  given  excellent  results. 
It  was  proposed  l)y  Dr.  G.  Gellhorn.  It  has  the  distinct  advantage  that,  in 
suital)le  cases,  the  foul  odor  and  the  bleeding  may  be  kept  away  without  the 
repeated  anesth.esia  necessary  where  dependence  is  placed  on  curetment  and 
cauterization  at  intervals.  It  is  applied  as  follows:  With  a  sharp  curet  all 
the  broken  down  tissue  is  cleared  out,  leaving  a  cavity  with  firm  walls.  This 
thorough  curetment  is  best  made  under  general  anesthesia.  The  cavity  is 
sponged  clear  of  blood  and  debris,  and  then  quickly  packed  with  gauze  wrung 
out  of  very  hot  water.  This  tends  to  check  the  oozing  and  is  to  be  held  firmly 
in  place  while  the  patient's  hips  are  elevated  to  the  Trendelenburg  posture 
in  preparation  for  the  acetone  application.  Then  the  vulva  and  vaginal  walls 
are  coated  with  vaseline,  the  hot  packing  is  removed  and  a  tubular  speculum 
large  enough  to  surround  the  greater  part  of  the  raw  cavity  is  introduced  and 
pressed  firmly  against  the  cervix.  The  pure  acetone  is  then  poured  into  the 
speculum  (through  a  funnel  or  simply  from  the  bottle)  in  sufficient  quantity 
to  fill  the  end  of  the  speculum  for  an  inch  or  so.  Keep  the  acetone  thus  in 
contact  with  the  raw  surface  for  thirty  minutes.  Then  the  acetone  is  removed 
by  soaking  it  up  with  cotton  in  forceps  or  by  lowering  the  table  and  allowing 
it  to  run  out  of  the  speculum.  After  the  cavity  is  dried  with  cotton,  a  tampon 
is  introduced  through  the  speculum  and  held  in  place  as  the  speculum  is  with- 
drawn. This  tampon  may  be  left  in  place  for  several  hours,  to  absorb  any 
acetone  left  and  thus  prevent  irritation  of  the  vaginal  wall.  The  coating 
of  the  vulvar  and  vaginal  surfaces  with  vaseline  is  to  prevent  irritation  by 
stray  drops  of  the  acetone.  The  acetone  application,  without  curetment,  is 
to  be  repeated  twice  weekly  until  the  cavity  is  well  contracted,  and  after  that 
occasionally  as  needed  to  prevent  bleeding  and  odor.  The  application  may 
last  30  to  45  minutes — the  longer  the  better  as  a  rule.  •  The  speculum  is  to  be 
held  in  place  all  this  time.  Usually  the  patient  can  steady  the  speculum  in 
place  after  having  been  shoM^n  how  to  do  so. 

7.  Partial  or  complete  vaginal  hysterectomy  as  a  palliative  measure  is  of 
service  in  suitable  cases.  By  this  means  a  large  part  of  the  cancerous  mass  is 
removed,  the  discharge  and  hemorrhage  are  checked,  pressure  in  the  pelvis  is 
relieved  and  the  patient  is  made  more  comfortable  for  several  months  and 
sometimes  longer. 


ggg  MALIGNANT  DISEASE  OF  THE  UTERUS 

Partial  extirpation  by  the  cautery,  after  the  method  of  Byrne,  is  the  prefer- 
able plan  usually.  A  large  part  of  the  cervix,  with  as  much  of  the  body  as 
seems  advisable,  is  extirpated  by  the  cautery  and  the  remaining  surfaces  are 
thoroughly  baked.  The  effect  of  the  heat  seems  to  have  some  influence  extend- 
ing a  considerable  distance  beyond  the  cauterized  tissues,  as  indicated  by  the 
long  freedom  from  recurrence  on  the  cauterized  surface,  though  the  deeper 
portions  of  the  infiltration  may  continue  to  grow.  When  applied  thoroughly 
in  a  way  to  secure  satisfactory  results,  amputation  is  almost  as  formidable 
an  operation  as  vaginal  hysterectomy  and  should  be  used  only  when  every- 
thing is  at  hand  to  meet  the  dangers  and  difficulties  that  may  arise. 

8.  Ligation  of  the  ovarian  arteries  and  other  easily  accessible  arteries  sup- 
plying the  region  of  the  tumor,  together  with  the  removal  of  the  adnexa,  may 
be  made  use  of  in  some  cases.  For  example,  where  there  has  been  an  explor- 
atory abdominal  section  and  the  carcinoma  is  found  inoperable,  the  vessels 
mentioned  may  be  ligated  to  diminish  the  blood  supply  and  retard  the  growth. 
The  effect  as  a  rule  is  not  very  marked.  Kosler  reports  several  cases  treated 
by  ligation.  There  was  some  temporary  improvement,  but  the  hemorrhage 
returned  in  a  short  time. 

9.  X-Ray  Treatment.  This  relieves  the  pain  and  bleeding  in  some  cases,  but 
the  high  claims  as  to  curative  results  in  cases  of  carcinoma  of  the  cervix  have 
not  been  sustained.  It  may  be  used  as  a  palliative  measure  in  inoperable  cases, 
but  even  then  it  is  not  likely  to  produce  as  good  results  as  a  partial  excision 
of  the  uterus  by  cautery  or  even  as  a  thorough  curetment  and  cauterization 
of  the  cavity.  It  is  still  on  trial,  its  exact  status  as  a  palliative  measure  hav- 
ing not  yet  been  thoroughly  established. 

The  effect  of  the  Finsen  Light  seems  to  be  less  than  that  of  the  X-Ray. 
The  effect  of  Radium  treatment  is  practically  nil. 

10.  Interstitial  Injections.  Injections  of  various  substances  into  the  cancer- 
ous mass  to  cause  sloughing  is  sometimes  used  with  benefit.  It  is  an  uncertain 
method,  however,  and  it  is  very  questionable  if  as  much  can  be  accomplished 
as  by  a  thorough  curetment  and  cauterization.  The  same  may  be  said  of 
various  substances  used  for  the  dissolving  of  fungus  cancerous  tissue. 

11.  Toxins.  Much  work  has  been  done  with  the  idea  of  developing  a  toxin 
or  antitoxin  or  serum  that  would  check  the  growth  of  malignant  tumors,  but 
so  far  nothing  satisfactory  has  been  created.  Coley's  toxin  (made  from  a 
culture  of  the  streptococcus  and  the  bacillus  prodigious)  has  produced  occa- 
sional beneficial  effects,  principally  in  sarcoma.  But  the  results  in  carcinoma 
have  not  been  such  as  make  its  use  Avorth  wbile.  Doyen's  cancer  serum 
proved  a  failure.  It  is  to  be  hoped  that  the  present  wave  of  investigation 
into  the  causes  of  malignant  disease  will  produce  something  of  real  value. 

CARCINOMA  OF  THE  CORPUS  UTERI. 

Adeno-carcinoma  is  the  variety  usually  found  here.  It  begins  in  the  endo- 
metrium, consequently  the  tumor  tissue  is  accessible  to  the  curet  at  a  very 
early  stage.     The  growth  is  for  a  long  time  confined  to  the  tissues  imme- 


CARCINOMA  OF  THE  CORPUS  UTERI 


687 


diately  about  the  uterine  cavity,  the  extension  to  the  periuterine  tissue  being 
slow  usually  in  carcinoma  of  Ihe  corpus  uteri — hence  the  chance  of  cure  is 


Fig.  623.  Beginning  Carcinoma  of  the  Corpus  Uteri.  There  is  no  external  sign  of  the  growth  at  this  stage, 
except  an  occasional  streak  of  blood  in  the  leucorrhoeal  discharge.  The  diagnosis  must  be  made  by  curetment. 
(Cullen — Cancer  of  the  Uterus.) 


Fig.  624.     Adeno-carcinoma  of  the  Corpus  Uteri  in  an  advanced  stage.     (Ciillen — Cancer  of  the  Uterus.-) 


688 


MALIGNANT  DISEASE  OF  THE  UTERUS 


much  better.  Cancers  of  the  corpus  uteri  constitute  a  distinct  class,  having 
a  better  prognosis  than  cancer  of  the  cervix  uteri,  and  requiring  as  a  rule 
less  extensive  operative  treatment.  A  carcinoma  of  the  corpus  uteri,  still  in 
an  early  stage,  is  shown  in  Fig.  623,  and  one  far  advanced  is  shown  in  Fig.  624. 
Chorio-epithelioma  is  a  peculiar  form  of  carcinoma  arising  from  the  fetal 
cells  covering  the  chronic  villi.  A  striking  feature  is  the  early  penetration  of 
blood-vessels,  with  resulting  metastases  to  distant  organs,  which  makes  it  an 
exceedingly  fatal  growth,  even  when  removed  comparatively  early.  Care 
should  be  taken  to  exclude  it  whenever  there  is  persistent  bleeding  coming  on 
some  weeks  or  months  after  confinement  or  miscarriage.  It  is  especially  liable 
to  occur  following  hydatidiform  mole.  Such  was  the  history  of  the  specimen 
shown  in  Fig.  625.     This  patient  was  brought  to  me  some  months  after  the 


Fig.  62.5.  A  Chorio-epithelioma  of  the  Uterus.  The  uterus,  which  is  about  one-half  larger  than  normal, 
has  been  opened  from  the  posterior  surface  and  spread  out.  Projecting  from  the  endometrial  surface  on  the 
right  side  near  the  fundus  is  a  nodule  which  has  been  incised.  It  is  the  size  of  a  walnut  and  extends  into  the 
waU  almost  to  the  peritoneum.  Sections  from  this  nodule  show  the  characteristic  structure  of  chorio-epi- 
thelioma. The  fact  that  in  chorio-epithelioma  there  is  early  erosion  of  the  blood  vessels  and  early  metastasis 
to  distant  organs  should  in  nowi.se  discourage  operation  in  this  class  of  tumors,  but  should  simply  stimulate 
us  to  greater  endeavor  to  make  the  diagnosis  at  the  earliest  possible  moment.  This  patient  was  heard  from 
more  than  five  years  after  the  operation,  and  was  still  well  and  with  no  evidence  of  recurrence. 


expulsion  of  a  large  hydatidiform  mole.  The  immediate  cause  of  the  consul- 
tation was  repeated  uterine  hemorrhage,  difficult  to  control.  Curettage  gave 
tissue  that  showed  malignant  disease  of  the -corpus  uteri.  I  then  did  a 
hysterectomy,  and  sectioning  of  the  removed  uterus  showed  a  typical  chorio- 
epithelioma. 

Malignant  adenoma  and  endothelioma  are  rare  forms  of  malignant  disease, 
which  do  not  require  special  description  here. 


SARCOMA  OF  THE  UTERUS  6g9 

Symptoms,   Diagnosis,   Treatment. 

The  symptoms  and  diagnosis  are  much  the  same  as  for  carcinoma  of  the 
cervix,  and  are  presented  in  detail  on  pages  670  to  672.  In  the  early  stage  a 
positive  diagnosis  can  ])e  made  only  by  curettage  and  microscopic  examination 
of  the  curettings.  Chronic  endometritis,  particularly  that  associated  with 
senile  changes,  is  the  affection  with  which  it  is  most  likely  to  be  confounded. 
A  very  practical  question  is,  "In  what  cases  is  it  advisable  to  do  curettage 
in  order  to  exclude  malignant  disease  of  corpus  uteri?"  In  all  cases  in  which 
llie  bloody  uterine  discharge  persists  in  spite  of  treatment  for  endometritis. 
AVhen  a  patient,  near  the  menopause,  comes  complaining  of  irregular  men- 
struation or  irregular  bloody  discharge,  and  examination  shows  no  trouble 
Avith  the  cervix,  no  uterine  fibroid  and  no  periuterine  disease,  I  assume  that 
the  bleeding  is  due  either  to  chronic  endometritis  or  to  beginning  malignant 
disease  of  the  endometrium.  If  the  cervix  is  somewhat  open,  I  try,  in  the 
office  examination,  to  secure  some  tissue  from  within  the  uterus.  If  this  is  not 
practical  and  the  probabilities  are  in  favor  of  endometritis,  I  put  the  patient 
on  the  ergotin  capsule  (see  Formulae)  and  watch  for  two  or  three  weeks. 
If  the  bloody  discharge  ceases,  that  points  to  endometritis  and  the  treatment 
is  continued.  If  the  bloody  discharge  persists  or  if  it  returns  after  cessation, 
tlien  I  insist  on  curettage.  In  such  a  case,  if  tissue  showing  positive  evidence 
of  malignancy  can  be  secured  in  the  office  examination,  it  obviates  double 
anesthesia.  On  the  other  hand,  malignant  disease  ordinarily  can  not  be  ex- 
cluded except  by  a  thorough  curettage  under  anesthesia,  which  means  sys- 
tematic removal  of  endometrial  tissue  from  all  parts  of  the  uterine  cavity. 
Another  important  point  is  that  all  the  curettings  must  be  preserved  and  sub- 
jected to  the  microscopic  examination.  For  points  in  regard  to  collecting 
and  transmitting  curettings  see  page  96. 

The  treatment  for  carcinoma  of  the  corpus  uteri  is  complete  hysterectomy 
at  once.  When  the  disease  is  discovered  early,  ordinary  hysterectomy,  either 
abdominal  or  vaginal,  will  practically  always  suffice  to  remove  all  involved 
tissue.  In  the  advanced  cases  removal  of  more  or  less  of  the  parametrium 
and  other  periuterine  tissues  is  required. 

SARCOMA  OF  THE  UTERUS. 

A  sarcoma  is  a  malignant  growth  arising  from  connective  tissue  or  con- 
nective tissue  derivatives.  The  cause  of  sarcoma,  like  that  of  carcinoma,  is  not 
known.  About  the  same  theories  have  been  brought  forward  to  account  for  it. 
Sarcoma  differs  from  carcinoma  in  that  it  may  occur  at  any  age  (though  more 
frequent  from  the  age  of  40  to  60),  and  furthermore  it  is  not  especially  asso- 
ciated with  child-bearing. 

Sarcoma  may  appear  as  a  general  infiltration  of  the  endometrium  or  as  a 
distinct  tumor.  By  edematous  change,  grape-like  masses  may  form,  either 
in  sarcoma  of  the  cervix  (Fig.  311)  or  in  sarcoma  of  the  body  of  uterus.  The 
sarcomata   beginning  in  the   endometrium   are    generally   of   the   round-cell 


690 


MALIGNANT  DISEASE  OF  THE  UTERUS 


variety.     Sarcomata  of  tlie  muscular  part  of  the  uterine  wall  usually  come 
from  sarcomatous  degeneration  of  jEibromyomata. 

The  sarcomata  grow  rapidly  or  slowly,  depending  on  the  character  of  the 
particular  tumor.  They  infiltrate  adjacent  tissues  like  the  carcinomata  and 
cause  death  in  about  the  same  time. 


Fig.  626.  Beginning  Sarcoma  of  the  Corpus  Uteri.  At  this  stage  there  is  no  external  evidence,  except 
blood  streaks  in  the  discharge.     Tlie  diagnosis  must  be  made  by  curetment.     (Kelly — Operative  Gynecology.) 

The  symptoms,  diagnosis  and  treatment  of  sarcoma  of  the  uterus  are  prac- 
tically the  same  as  for  carcinoma.  A  beginning  sarcoma  is  shown  in  Fig.  626, 
and  one  more  advanced  in  Fig   627.     It  sometimes  occurs  in  children.     Occa- 


Fig.  627.     Advanced  Sarcoma  of  the  Corpus  Uteri.     (KeUy^Ojxnitivr  Gi/necologij.) 

sionally  it  appears  in  the  form  of  a  grajx^-lih'e  mass  attached  io  the  cervix,  as 
shown  in  Fig.  IHl.  A  ix'diculated  safcoiua,  jii'ojecting  into  the  vagina  is 
shown  in  Fig.  .110.  A  sarcoma  originating  in  a  tibi-oid  is  shown  in  Figs.  613 
and  614. 


691 


CHAPTER  X. 

PELVIC  INFLAMMATION. 

Pelvic  inflammation  is  the  term  applied  to  inflammation  in  tlie  pelvis  outside 
the  uterus.  The  inflammatory  process  may  be  located  in  the  Fallopian  tubes, 
in  Avliich  case  it  is  called  "salpingitis,"  or  it  may  be  in  the  ovary,  in  which 
case  it  is  called  "oophoritis,"  or  in  the  peritoneum,  where  it  is  known  as 
"pelvic  peritonitis,"  or  it  may  be  in  the  connective  tissue,  where  it  constitutes 
"pelvic  cellulitis."  The  cause  of  these  various  forms  of  inflammation  is  the 
same — viz.,  infection — the  symptoms  are  much  the  same,  the  treatment  is  in 
many  respects  the  same,  and  two  or  three  of  the  lesions  are  usually  associated — 
in  some  cases  so  intimately  associated  that  it  is  difficult  to  determine  which 
is  the  most  important.  Consequently,  from  a  practical  standpoint,  it  is  best 
to  consider  all  these  lesions  together  under  the  one  comprehensive  term 
"pelvic  inflammation." 

Before  taking  up  the  disease  proper,  I  wish  to  call  attention  to  some  points 
in  the  anatomy  of  the  structures  involved. 

POINTS  IN  ANATOMY 

Of  Fallopian  Tubes,   Pelvic  Peritoneum,   Pelvic    Connective   Tissue. 

FALLOPIAN  TUBES. 

The  Fallopian  tubes,  or  oviducts,  are  two  small  muscular  tubes,  one  on 
either  side,  which  extend  from  the  fundus  uteri  outward  in  the  upper  part 
of  the  broad  ligament  toward  the  pelvic  wall  (Figs.  4,  5).  Each  tube  has  a 
small  central  cavity  extending  its  whole  length  (Fig.  531).  The  inner  end 
of  this  cavity  communicates  with  the  uterine  cavity  and  the  outer  end  opens 
into  the  peritoneal  cavity.  Thus  there  is  a  direct  opening  from  the  outside 
of  the  body  into  the  great  peritoneal  sac,  through  the  vagina,  uterus  and  Fal- 
lopian tubes  (Fig.  628).  This  is  why  infection  of  the  genital  tract  in  a  Avoman 
leads  to  peritonitis  so  much  more  frequently  than  infection  of  the  genital  tract 
in  a  man— the  infection  in  the  vagina  simply  extending  along  this  mucous 
tract  directly  into  the  peritoneal  cavity. 

The  tubes  vary  considerably  in  size  and  somewhat  in  shape  in  different 
individuals.  The  length  of  each  tube  is  three  to  five  inches  and  the  direction 
is  outward,  backward,  downward  and  inward — somewhat  resembling  a  shep- 
herd's crook  and  partly  surrounding  the  ovary  (Fig.  4). 

That  portion  of  the  tube  lying  in  tlie  uterine  wall  is  knoAvn  as  the  interstitial 
portion  or  uterine  portion.  It  has  a  very  narrow  lumen  (Fig.  531).  That 
portion  of  the  tube  extending  from  the  margin  of  the  uterus  to  the  beginning 


692 


PELVIC  INFLAMMATION 


of  the  curve  is  called  isthmus.  It  is  about  the  diameter  of  a  slate  pencil  and 
is  firm.  The  lumen  is  small,  but  becomes  gradually  larger  toward  the  outer 
end.  The  outer  curved  dilated  portion  of  the  tube  is  known  as  the  ampulla. 
It  is  about  the  size  of  a  lead  pencil  and  the  lumen  also  is  much  larger  than 
that  of  the  isthmus  (Fig.  531).     The  outer  end  of  the  tube  is  kno^vn  as  the 


=  o    sa*i 


Fig.  628.  A  Diagrammatic  Section  of  tlie  Cenital  Canal.  Notice  the  continuous  opening  from  the  ^•ulva 
through  the  vagina,  uterus  and  Fallopian  tube.s  to  the  peritoneal  cavity.  This  is  the  rea.son  genital  infection 
extends  to  the  peritoneal  cavitj'  so  much  more  frequently  in  women  than  in  men.     (Waldeyer — Dns  Bccken.) 


fimbriated  extremity  or  the  infundibulum.  This  consists  of  a  funnel-shaped 
expansion  surrounded  by  a  fringe  of  slender,  finger-like  processes  called 
"fimbriae."  One  of  these  extends  to  the  ovary  and  is  attached  there  and  is 
called  the  "ovarian  fimliria. " 

In  structure  the  wall  of  the  tube  is  largely  muscular,  resembling  the  uterus. 


POINTS  IN  ANATOMY  693 

In  fact  it  is  derived  from  the  same  fetal  organ  as  the  uterus  (Fig.  704).  The 
tube  lies  beneath  tlie  peritoneum  of  the  upper  margin  of  the  broad  ligament 
and  its  wall  presents  three  layers — peritoneal,  muscular  and  mucous. 

The  peritoneal  layer  does  not  differ  materially  from  peritoneum  elsewhere. 
It  is  composed  of  fiat  endothelial  cells  lying  on  a  basis  of  firm  connective 
tissue.  Immediately  beneath  the  peritoneum  is  a  layer  of  connective  tissue 
sometimes  called  the  subperitoneal  layer.  In  this  run  blood  vessels  and  lym- 
phatics. The  interstitial  portion  of  the  tube  has,  of  course,  no  peritoneal  layer, 
as  the  muscular  tissue  of  the  tube  is  in  immediate  contact  with  the  muscular 
tissue  of  the  Avail  of  the  uterus. 

The  muscular  layer  of  the  tube  is  composed  of  involuntary  muscular  tissue, 
disposed  in  two  strata,  an  outer  longitudinal  and  an  inner  circular.  Both 
these  strata  are  continuous,  with  similar  muscular  strata  in  the  uterus.  The 
internal  stratum  sends  prolongations  of  muscular  tissue  into  the  four  principal 
folds  of  the  mucosa.  The  muscular  layer  is  thinner  at  the  abdominal  end 
than  at  the  uterine  portion  of  the  tube.  The  increased  thickness  of  the  wall 
at  the  abdominal  end  of  the  tube  is  due  to  the  many  folds  of  mucosa. 

The  mucous  layer  of  the  tube,  like  the  uterine  mucosa,  is  placed  directly 
upon  the  muscular  layer — there  is  no  intervening  submucosa.  The  surface 
of  the  mucous  membrane  is  formed  of  a  layer  of  ciliated  cylindrical  cells. 
The  cells  are  somewhat  taller  than  those  lining  the  body  of  the  uterus  and 
not  so  tall  as  those  lining  the  cervix  uteri.  Beneath  the  epithelial  layer  the 
mucosa  is  composed  of  "stroma  cells,"  very  much  like  those  found  in  the 
uterus,  except  slightly  smaller.  Between  the  stroma-cells  is  a  delicate  con- 
nective-tissue framework.  There  are  found  also  capillary  blood  vessels  and 
small  lymph  channels. 

There  are  no  glands  in  the  tubal  mucous  membrane.  The  depressions 
which  look  like  glands  are  due  simply  to  the  folds  of  the  mucous  membrane. 
As  there  are  no  glands  in  the  tube,  there  can  be  no  mucus  secretion,  such  as 
takes  place  in  the  uterus.  The  fluid  by  which  the  tube  is  distended  in  certain 
pathological  conditions  is  inflammatory  exudate  and  not  glandular  secretion. 

The  mucous  membrane  is  much  folded  longitudinally  (Fig.  531).  There  are 
four  principal  folds  into  which  prolongations  of  the  muscular  tissue  take  place. 
There  is  no  muscular  tissue  in  the  many  smaller  folds.  In  the  interstitial  por- 
tion and  in  the  isthmus  the  folds  are  few  and  simply  longitudinal  (Fig.  629), 
but  in  the  outer  portion  of  the  tube  (the  ampulla)  they  become  very  complex 
and  fill  the  tube  with  folds  extending  in  every  direction  (Fig.  630) — so  much 
so  that  it  is  sometimes  difficult  to  decide  which  is  the  main  canal  of  the  tube. 
The  cilia  of  the  epithelium  project  into  the  lumen  of  the  tube  and  by  their 
movement  toward  the  uterus  aid  the  passage  of  the  ovum  in  that  direction. 
In  the  presence  of  this  delicate  and  much-folded  mucous  membrane,  inflam- 
mation in  the  tube  quickly  causes  serious  changes.  The  cilia  are  lost,  the 
folds  become  adherent,  pockets  of  serum  or  pus  form,  and  the  picture  of  the 
tubal  interior  may  be  so  changed  as  to  be  hardly  recognizable. 

Vessels  and  Nerves.     The  blood  supply  of  the  tube  comes  from  the  ovarian 


694 


PELVIC  INFLAMMATION 


arterr  tlirougli  several  small  brandies.     The  uterine  artery  helps  to  supply 
the  tube  in  some   cases.     The  veins   open  into   the  pampiniform   or   ovarian 


Fig.  629.     Cross  Section  of  a  Normal  Fallopian  Tube,  near  the  Uterine  End.     (Penrose,  after  Beyea — Dis- 
eases of  Women.) 

plexus  and  pass  into  the  broad  ligament.     The  lymphatics  join  with  those 
from  the  ovary.    The  nerve  supply  comes  from  the  pelvic  plexus  of  each  side. 


Fig.  630.     Cros.s  Section  of  .the  Fallopian  Tube,  near  the  Fimhri;tte>l  Extremity.     (Penrose,  after  Bevea  — 
Diseases  of  Women.) 


POINTS  IN  ANATOMY  695 

Physiology.  The  primary  rimction  of  the  Fallopian  tube  of  each  side  is 
to  convey  ova  from  the  corresponding  ovary  to  tlie  utenis.  It  is  supposed 
to  require  several  days  for  the  ovum  to  ]);iss  the  leiij^th  of  the  tube.  In 
addition  to  this,  the  tidie  conveys  speriiuitozoa  in  the  opposite  direction,  and 
it  is  usually  in  the  tube  that  the  union  of  the  ovum  and  the  spermatozoon 
takes  place. 

The  mechanism  by  which  the  ovum  is  carried  from  the  ovary  into  the  tube 
is  complicated.  After  the  Graafian  follicle  in  the  ovary  l)ursts,  the  liquor  fol- 
lictdi  causes  the  ovum  to  adiiere  slif,ditly  to  th<;  surface  of  tin;  ovary.  Some  of 
the  fimbriae  are  in  contact  with  the  surface  of  the  ovary  and,  when  an  ovum 
comes  in  contact  with  one  of  them,  tlu;  cilia  carry  it  towards  the  entrance  of 
the  tube.  Besides  this  action  of  the  cilia  directly  on  the  ovum,  the  constant 
movement  of  all  the  cilia  causes  a  slight  current  of  peritoneal  fluid  toward 
the  interior  of  the  tube  from  all  directions.  This  helps  to  carry  the  ovum 
or  any  other  small  particles  into  the  tube.  The  fact  that  there  is  such  a  cur- 
rent towards  the  interior  of  the  tube  has  been  demonstrated  by  the  injection 
into  the  pelvic  peritoneal  cavity  of  animals  of  numerous  small  insoluble  par- 
ticles, which  were  found  later  in  the  tubes. 

It  has  been  suggested  that  the  fimbriated  extremity  of  the  tube  grasps  the 
ovary  when  an  ovum  is  discharged,  but  this  has  not  been  proven. 

Normal  Changes  in  the  Tube. 

In  studying  the  anatomy  of  the  uterus  it  was  found  that  that  organ,  particu- 
larly the  mucosa,  was  subject  to  normal  changes  under  three  conditions — 
namely,  menstruation,  pregnancy  and  the  menopause.  Now,  in  the  Fallopian 
tube  also,  we  find  normal  changes,  due  to  menstruation,  to  pregnancy  and  to 
the  menopause.  Speaking  generally,  it  may  be  said  that  these  changes  are 
like  those  occurring  in  the  uterus,  but  less  marked. 

During  menstruation  there  is  congestion  of  the  tube  and  possibly  a  slight 
effusion  of  blood  into  the  interior  of  the  tube.  If  this  does  take  place,  how- 
ever, it  is  slight  and  is  of  no  importance  when  considering  the  source  of  the 
menstrual  blood.  Practically  all  of  tlie  menstrual  blood  comes  from  the 
uterus.  In  a  case  of  removal  of  the  uterus  by  operation  and  the  fastening  of 
one  of  the  tubes  in  the  vaginal  incision,  a  slight  bloody  flow  was  noticed  at 
the  menstrual  periods  for  a  few  months.  But  such  tubes  are  pathologic,  and 
it  is  an  open  question  whether  or  not  a  bloody  flow  Avould  take  place  from  a 
normal  tube. 

In  pregnancy  (normal  pregnancy,  not  tubal  pregnancy)  the  tube  wall  and 
mucous  membrane  become  thickened  and  the  folds  enlarged.  The  vessels  also 
become  larger,  especially  the  veins  and  lympliatics.  After  confinement  the 
tube  undergoes  involution  along  with  the  uterus. 

After  the  menopause  the  tube  shows  certain  senile  changes.  There  is  dis- 
appearance of  the  cilia,  diminution  in  the  size  of  the  tube,  shrinking  of  the 
connective  tissue  and  shrinking  of  the  mucosal  folds.  The  tube  becomes 
smaller  and  firmer,  and  is  no  longer  a  functionating  structure. 


696  PELVIC  INFLAMMATION 

PELVIC   PERITONEUM. 

The  pehdc  peritoneum  is  that  portion  of  the  wall  of  the  peritoneal  sac  which 
lies  in  the  peMs.  It  is  attached  more  or  less  closely  to  the  pelvic  organs  and 
its  free  surface  comes  in  contact  with  the  peritoneal  surface  of  the  intestines 
as  they  move  about  in  the  lower  abdomen.  To  get  an  idea  of  the  distribution 
of  the  peritoneum  in  the  pelvis,  imagine  a  piece  of  thin  cloth  laid  over  the 
pelvic  organs  and  tucked  down  firmly  around  them  (Fig.  550 j. 

Starting  from  the  abdominal  wall,  the  peritoneum  passes  onto  the  bladder^ 
and  from  the  posterior  surface  of  the  bladder  to  the  uterus  (Fig.  3).  The 
height  of  the  abdomino-vesical  fold  of  peritoneum  varies  much  Avith  the  vary- 
ing size  of  the  bladder,  which  fact  is  of  much  importance  in  surgical  work. 
The  distance  to  which  the  peritoneum  extends  do^vn  the  anterior  surface  of 
the  uterus  varies  considerably  in  different  persons.  Usually  it  extends  to  the 
level  of  the  internal  os  and  is  about  an  inch  above  the  anterior  vaginal  fornix. 
When  the  bladder  is  distended,  the  peritoneum  is  drawn  upward  somewhat. 
This  vesico-uterine  fold  of  peritoneum  forms  the  two  so-called  "vesico-uterine 
ligaments."' 

The  peritoneum  then  folds  over  the  uterus  and  tubes  and  round  ligaments, 
covering  these  structures  and  forming  the  ''broad  ligament"  of  each  side. 
All  the  posterior  surface  of  the  uterus  is  covered  with  peritoneum,  except  that 
portion  lying  ^\dthin  the  vagina.  The  fold  of  peritoneum  extends  a  consider^ 
able  distance  below  the  point  of  attachment  of  the  vagina  to  the  uterus 
(Fig.  3)  before  being  reflected  on  to  the  rectum.  The  deep  pouch  of  peri- 
toneum thus  formed  is  called  the  ''cul-de-sac  of  Douglas"  (Fig.  4).  It  is 
known  also  as  the  "posterior  cul-de-sac"  and  as  the  "posterior  peritoneal 
pouch"  and  as  the  "recto-uterine  pouch."  This  posterior  cul-de-sac  is  very 
important  surgically.  A  collection  of  exudate  or  a  tumor  in  this  situation 
can  be  easily  felt  from  the  posterior  vaginal  fornix.  This  is  the  point  of 
incision  in  posterior  vaginal  section,  and  it  is  usually  the  first  place  that 
the  peritoneal  canity  is  entered  in  vaginal  hysterectomy. 

The  peritoneum,  as  it  is  reflected  from  the  uterus  to  the  rectum,  helps  to 
form  the  "sacro-uterine  ligaments."  The  sacro-uterine  ligaments,  two  in 
number,  one  on  each  side,  extend  backward  from  the  lower  part  of  the  uterus 
aroimd  the  rectum  to  the  sacrum.  They  are  composed  of  connective  tissue, 
a  few  muscular  fibers  and  peritoneum.  The  cul-de-sac  of  Douglas  dips  down 
between  them  for  a  considerable  distance  (Fig.  4).  The  expanse  of  peri- 
toneum extending  from  the  sacro-iliac  ligament  to  the  broad  ligament  of  eacli 
side  forms  a  kind  of  shelf.  The  two  together  are  sometimes  called  the  "recto- 
uterine shelves."  Tliere  is  also  a  fold  or  shallow  poiich  of  peritoneum  on  eacli 
side  between  the  Fallopian  tube  and  the  round  ligament.  A  small  portion  of 
the  uterus  at  the  sides  and  in  front  is  not  covered  with  peritoneum  (Fig.  539). 

The  structure  of  the  pelvic  peritoneum  is  much  the  same  as  of  peritoneum 
elsewhere.  It  is  a  very  thin  and  smooth  membrane,  formed  of  a  basis  of 
delicate  fibrous  and  elastic  tissue,  supporting  large  endothelial  cells. 


I 


POINTS  IN  ANATOMY 


697 


PELVIC   CONNECTIVE   TISSUE. 

Between  the  peritoneum  and  the  reeto-vesical  fascia  there  is  connective 
tissue.  This  is  distributed  so  as  to  fill  in  all  the  spaces  (Figs.  539,  631). 
AVhen  it  is  necessary  for  organs  to  change  their  relation  to  each  other  in 
physiological  activity,  the  connection  is  open  and  loose  so  as  to  permit  free 
movement  and  much  stretching.  The  principal  collections  of  connective  tissue 
are  at  the  sides  of  and  in  front  of  the  cervix  uteri  and  at  the  base  of  each 
broad  ligament.     The  areas  of  connective  tissue  are  exceedingly  rich  in  lym- 


Fig.  631.  The  Connective  Tissue  of  the  Pehis.  Left  side  of  pehis — section  through  cervix,  showing  the 
large  area  of  connective  tissue  at  side  of  ce^^ix.  Pught  side — section  at  higher  level,  showing  how  the  broad 
ligament  becomes  thinned,  lea^-ing  only  a  small  amount  of  connective  tissue  at  side  of  corpus  uteri. 

phatics  and  veins.     Inflammation  taking  place  in  the   connective  tissue  is 
called  "pelvic  cellulitis." 

The  connective  tissue  about  the  uterus  is  often  spoken  of  collectively  as 
the  "parametrium"  of  parametrial  tissue,  and  inflammation  of  the  same  is 
accordingly  called  "parametritis."  This  is  a  very  convenient  term,  but  is 
likely  to  be  confounded  with  the  similarly  sounding  word  "perimetritis." 
The  latter  means  inflammation  of  the  structures  about  the  uterus,  particularly, 
however,  of  the  peritoneum  and  adnexa.    In  writing,  these  two  terms  may  be 


698  ACUTE  PELVIC  INFLAMMATION 

safely  used,  but  in  conversation  they  are  very  liable  to  be  confounded,  as  they 
sound  so  much  alike. 

It  was  formerly  supposed  that  nearly  all  inflammation  in  the  pelvis  outside 
the  uterus  was  inflammation  of  the  connective  tissue  (i.  e.,  pelvic  cellulitis), 
but  it  has  been  found  that  in  the  majority  of  cases  the  inflammation  invades 
first  the  tube  and  later  the  peritoneum,  and  that  usually  the  involvement  of 
the  connective  tissue,  if  present  at  all,  is  a  late  development  and  of  only 
secondary  importance.  There  are  exceptions  to  this  rule — for  example,  those 
inflammatory  conditions  resulting  from  tears  of  the  cervix  or  from  operation 
on  the  cervix.  Also  in  puerperal  infections,  particularly  streptococcic,  the 
inflammation  very  frequently  extends  directly  through  the  wall  of  the  uterus 
in  the  pelvic  connective  tissue. 

ACUTE  PELVIC  INFLAMMATION. 

Coming  now  to  the  consideration  of  tlie  disease  itself,  we  find  that  pelvic 
inflammation  may  be  acute  or  chronic.     Let  us  consider  first  the  acute  variety- 

The  inflammatory  process  may  be  in  the  Fallopian  tubes  (salpingitis),  or 
in  the  ovaries  (oophoritis),  or  in  the  peritoneum  (pelvic  peritonitis),  or  in  the 
connective  tissue  (pelvic  cellulitis). 

ETIOLOGY. 

The  cause  of  acute  pelvic  inflammation  is  infection.  The  infection  may  be 
with  the  ordinary  pus  germs  (staphylococcus  and  streptococcus)  or  with  the 
gonococcus.  Practically  every  case  of  primary  acute  pelvic  inflammation  in 
the  adult  can  be  traced  to  infection  from  labor,  from  abortion,  from  instru- 
mentation or  from  gonorrhoea.  Secondary  inflammation  of  the  genital  organs 
may  be  caused  by  extension  from  an  inflammatory  focus  in  some  adjacent 
organ — e.  g.,  the  appendix  or  the  bladder. 

In  a  large  proportion  of  the  cases  of  pelvic  inflammation,  particularly  the 
gonorrhoeal  cases,  the  infection  extends  by  way  of  the  uterine  mucosa  to  the 
Fallopian  tubes,  and  through  the  tubes  to  the  peritoneum  and  other  pelvic 
structures.  In  puerperal  metritis  (streptococcic  or  staphylococcic)  the  infec- 
tion more  often  extends  by  Avay  of  the  lymphatics  directly  through  the  wall 
of  the  uterus,  from  tlie  endometrium  to  the  connective  tissue  around  the 
uterus,  and  to  the  peritoneum.  Another  avenue  of  entrance  is  through  the 
thrombosed  sinuses  of  the  puerperal  uterus.  Infection  of  these  sinuses  leads 
to  infective  thrombosis  of  the  broad-ligament  veins,  resulting  in  broad-liga- 
ment abscess  or  .general  pyaemia  or  both. 

The  fact  that  nearly  every  case  of  pelvic  inflammation  is  due  to  an  infected 
endometritis  emphasizes  the  importance  of  checking  endometritis  at  once 
when  present  and  of  preventing  it  whenever  possible. 


PATHOLOGY  g99 

PATHOLOGY. 

The  pathological  changes  are  varied.  There  are  hardly  two  cases  exactly 
alike  and  the  same  case  presents  a  very  different  picture  at  diiferent  periods. 
However,  the  cases  may  be  divided  somewhat  into  classes,  as  foUoAvs : 

1.  Mild  Salpingitis.  The  inflammation  is  very  slight.  There  is  some  round 
cell  intiltratiou  of  the  wall  of  the  tube,  Avith  slight  thickening  and  hardening, 
and  a  few^  fimbriae  bound  together.  Both  ends  of  the  tube  are  open.  This  is 
Ihe  miklest  form  of  pelvic  inflammation,  and  as  a  rule  gives  rise  to  very  few 
sym[)loms.  A  more  severe  type  of  the  same  class  is  that  in  which  both  ends 
of  the  tube  are  occluded  and  the  flmbriae  are  matted  together,  and  the  tube 
distorted  and  often  adherent  to  the  ovary  or  to  some  other  structure.  Tlie 
Avail  of  the  tube  is  thickened,  but  the  cavity  contains  no  appreciable  amount 
of  fluid. 

2.  Salpingitis  with  Exudate.  In  the  cases  of  this  class  there  is  a  large 
amount  of  exudate,  binding  together  the  tubes,  ovaries,  intestines  and  uterus. 
But  there  is  no  distinct  collection  of  pus. 

3.  Pyosalpinx  (Tubal  Abscess).  The  tube  is  distended  with  pus  (Fig.  416) 
and  there  are  the  usual  evidences  of  inflammation  within  and  without  the 
tube,  but  no  pus  outside  the  tube.  There  may  or  may  not  be  a  large  mass 
of  exudate.  In  exceptional  cases  the  infection  may  localize  in  the  ovary 
instead  of  in  the  tube,  causing  an  ovarian  abscess.  In  still  other  cases  the 
abscess  caAdty  involves  both  the  tube  and  the  ovary,  forming  the  tubo-ovarian 
abscess. 

4.  Diffuse  Suppuration  in  Pelvis.  In  this  fourth  class  the  pus  itself  has 
extended  outside  the  tube,  the  fibrinous  exudate  always  extending  before  it 
and  shutting  it  off  from  the  general  peritoneal  cavity.  This  may  result  simply 
in  an  abscess  low  in  the  pelAds,  which  can  be  easily  reached  and  CA^acuated 
from  below,  or  the  inflammation  may  extend  until  all  the  pelvic  organs  are 
bound  together  in  an  irregular  mass,  with  pus  lying  in  the  spaces  betAveen 
them  and  burroAving  into  the  connective  tissue.  In  such  a  case  there  are 
present  all  the  lesions  of  pelvic  inflammation — salpingitis,  oophoritis,  peri- 
tonitis and  cellulitis. 

5.  Acute  Diffuse  Peritonitis.  In  cases  of  this  class  the  infection  is  so  viru- 
lent and  spreads  so  rapidly  that  but  little  limiting  exudate  is  formed.  The 
infection  quickly  involves  the  general  peritoneal  cavity  and  causes  a  fatal 
peritonitis.  This  is  an  unusual  form  of  pelvic  inflammation  and  is  found 
principally  in  cases  of  severe  sepsis  folloAving  labor  or  abortion. 

6.  Cellulitis  (Fig.  386).  This  is  largely  a  lymphangitis  of  the  connective 
tissue  about  the  uterus.  It  is  due  usually  to  the  streptococcus,  the  staphylo- 
coccus or  the  colon  bacillus — rarely,  if  ever,  to  the  gonococcus  alone.  Cellu- 
litis is  favored  by  deep  laceration  of  the  cervix,  AA^hieh  opens  up  the  con- 
nective area  beside  the  uterus.  Pehdc  cellulitis,  like  inflammation  of  con- 
nective tissue  elsewhere,  may  end  in  resolution  or  abscess  formation  or  gen- 
eral sepsis.  If  resolution  takes  place  or  if  an  abscess  forms  and  is  opened, 
ihe  inflammation  subsides,  leaAing  only  infiltration   and  scar  tissue,   Avhich 


700 


ACUTE  PELVIC  INFLAMMATION 


causes  but  few  symptoms  aside  from  distortion  of  the  parts.  The  inflamma- 
tion may,  however,  extend  to  the  peritoneum,  in  which  cases  there  are  added 
the  evidences  of  pelvic  peritonitis. 


Fig.  632.  PehicThrombo-phlebitis.  The  left  broad  liRainent  has  been  laid  open,  and  thesiteof  the  upper 
and  lower  group  of  thrombosed  veins  indicated.  The  right  ovarian  vein  is  shown  thrombosed  almost  to  its 
termination  in  the  vena  cava. 

7.  Septic  Thrombosis  (Fig.  632).  This  comes  from  infection  of  the  normal 
thrombi  tilling  the  uterine  sinuses  after  labor.     It  constitutes  a  severe  and 


SYMPTOMS  701 

often  fatal  funu  of  puerperal  sepsis.  In  tlie  effort  to  limit  the  infective  and 
destructive  process  in  the  sinus  or  vein,  nature  causes  another  thrombus  to 
form  proximal  to  the  infected  one.  If  the  infection  extends  into  the  new 
thrombus,  a  portion  of  the  vein  proximal  to  that  in  turn  becomes  thrombosed. 
This  process  may  keep  on  until  the  veins  of  the  broad  ligament  become  exten- 
sively throm])osed.  If  the  infection  enters  through  the  upper  part  of  the 
uterus  (the  usual  placenta!  site),  it  affects  the  ovarian  veins  in  the  upper  part 
of  the  broad  ligament  (Fig.  632,  left  side).  If  it  enters  through  the  lower 
portions  of  the  uterus,  the  resulting  septic  thrombosis  affects  the  uterine  veins 
lower  in  the  broad  ligament  (Pig.  632). 

If  nature  succeeds  in  limiting  the  process  to  this  region,  pockets  of  pus 
may  form  in  the  thrombosed  veins  and  break  into  the  connective  tissue,  form- 
ing a  pelvic  abscess,  which  can  be  recognized  and  opened.  If  nature  does  not 
succeed  in  limiting  the  process,  it  extends  centrally — along  the  ovarian  veins 
(Fig.  632)  toward  the  vena  cava,  or  along  the  lower  veins  to  the  internal  iliac, 
the  common  iliac  and  finally  to  the  vena  cava.  When  the  common  iliac  is 
involved,  the  process  extends  downward  also  along  the  external  iliac  vein,  pro- 
ducing the  usual  signs  of  external  iliac  thrombosis  (so-called  "milk  leg").  It 
must  be  kept  in  mind,  however,  that  external  iliac  thrombosis  may  or  may  not 
be  septic  thrombosis,  many  cases  occurring  without  any  evidence  of  sepsis.  At 
any  stage  of  the  septic  process  in  the  veins,  infected  particles  may  become 
detached  and  pass  into  the  general  circulation,  giving  rise  to  metastatic  foci 
in  various  parts  of  the  body,  and  constituting  general  pyaemia. 

SYMPTOMS. 

A  patient  with  acute  pelvic  inflammation  complains  of  pain  in  the  lower 
abdomen,  increased  by  movements,  such  as  walking  or  turning  over  or  sitting 
up.  She  is  usually  confined  to  bed.  There  may  be  moderate  fever  (101°  to 
103°)  or  there  may  be  high  fever  (105°),  the  high  temperature  being  found 
most  frequently  in  pelvic  inflamm.ation  following  labor  or  miscarriage. 

There  is  usually  a  vaginal  discharge,  due  to  the  coincident  inflammation  of 
the  endometrium,  and  there  is  a  history  of  a  recent  labor  or  abortion,  or  instru- 
mentation or  gonorrhoea,  or  a  history  of  a  chronic  endometritis  due  to  one  of 
these  causes. 

On  abdominal  examination  the  lower  abdomen  is  found  to  be  tender  on 
pressure.  This  tenderness  may  be  confined  to  one  or  both  tubal  regions  or  it 
may  extend  over  all  the  lower  abdomen.  On  account  of  this  tenderness  the 
abdominal  muscles  are  held  more  or  less  tense,  thus  preventing  deep  palpation. 

In  the  vaginal  examination  the  character  of  the  discharge  is  determined, 
indicating  to  some  extent  the  etiology  of  the  trouble,  and  there  is  noticed  also 
the  presence  or  absence  of  evidences  of  recent  labor  or  miscarriage.  iManipu- 
lations  in  the  upper  part  of  the  vagina  cause  pain.  This  tenderness  on  vaginal 
palpation  and  bimanual  palpation  is  found  both  in  the  body  of  the  uterus  and 
about  the  tube  of  one  or  both  sides.  If  a  mass  of  exudate  is  present,  it  may 
be  felt  to  one  side  of  the  uterus  or  behind  it.    If  the  exudate  is  low  in  the 


702  ACUTE  PELVIC  INFLAMMATION 

pelvis — for  example,  in  the  posterior  cul-de-sac  or  about  a  prolapsed  ovary  or 
tube — it  may  be  easily  felt  back  of  the  uterus  just  above  the  posterior  vaginal 
formix.  If  the  exudate  is  situated  high  in  the  pelvis,  it  may  require  very  deep 
bimanual  palpation  to  detect  it,  and  the  deep  bimanual  palpation  may  be  im- 
possible at  first  on  account  of  the  tension  of  the  abdominal  muscles.  The  mass 
of  exudate  is  distinguished  hy  its  being  more  resistant  (firmer)  than  the  sur- 
rounding tissues  and  more  tender  on  pressure.  The  exudate  may  extend  all 
around  the  uterus,  fixing  that  organ  as  though  plaster  of  Paris  had  been 
poured  into  the  pehds  and  had  hardened  there.  In  these  cases  of  extensive 
distribution  of  the  exudate  the  sensation  imparted  to  the  examining  fingers 
is  that  of  a  firm  roof  across  the  pelvis  just  above  the  vagina  (Fig.  401).  The 
uterus  projects  through  this  roof  of  exudate  and  is  held  firmly  by  it. 

If  there  is  a  collection  of  pus  of  considerable  size,  fluctuation  may  be  de- 
tected, the  soft  area  being  surrounded  by  a  firm  area  of  exudate  which  has 
not  yet  broken  down.  If  there  is  only  a  small  collection  of  pus,  not  large, 
enough  to  give  fluctuation,  its  presence  is  indicated  by  persistent  fever  and 
its  location  is  shown  by  a  point  of  marked  tenderness.  When  there  is  an  in- 
flammatory exudate  in  the  posterior  cul-de-sac,  fluctuation  may  in  some  cases 
be  detected  earlier  by  rectal  than  by  vaginal  examination,  the  rectal  finger 
being  able  to  palpate  the  posterior  surface  of  the  mass. 

In  septic  thrombosis  without  other  involvement  and  in  puerperal  pyaemia 
there  may  be  no  evidence  of  pelvic  peritonitis  nor  of  pelvic  cellulitis — simply 
repeated  chills  and  high  fever  without  any  palpable  local  lesion  of  sufficient 
extent  to  accoumt  for  them.  There  is  tenderness  in  the  region  of  the  veins 
affected,  and  in  some  cases  distinct  induration  may  be  made  out,  particularly 
where  there  is  more  or  less  peri-venous  inflammation.  If  the  infection  has 
come  through  the  upper  part  of  the  uterus  (which  is  the  usual  location  of  the 
placental  site  and  hence  of  the  area  of  penetration),  the  ovarian  veins  are  the 
ones  most  likely  to  be  aft'ected.  In  many  cases  they  alone  have  been  found 
involved  (Fig.  632,  right  side).  When  the  infection  penetrates  the  lower  part 
of  the  uterus,  the  uterine  veins  and  broad-ligament  veins  generally  become 
affected,  and  later  the  internal  and  common  iliac  veins. 

DIAGNOSIS. 

The  disease  that  may  l)e  confused  witli  acute  pelvic  inflammation  and  that 
must  therefore  be  taken  into  consideration  in  the  differential  diagnosis  are  as 
follows : 

Acute  endometritis.  . 

Tubal  pregnancy. 

Appendicitis. 

A  tumor  which  has  become  gangrenous  from  twisted  pedicle. 

A  suppurating  tumor  (usually  a  dermoid  cyst  or  a  necrotic  fibroid). 
In  acute  endometritis  the  bimanual  examination  shows  that  the  tenderness 
is  limited  to  the  uterus.    There  is  no  marked    tenderness  in  the    peri-uterine 
structures,  nor  is  any  mass  found  there. 


DIPFERENTIAI,  DIACNOSI.S  703 

Tubal  pregnancy  has  hern  so  many  limes  mistaken  for  ui-clinary  peh'ie  in- 
flammation that  the  differential  diagnostic  points  shonkl  be  considered  in 
detail  (see  Tul)al  Pregnancy). 

In  appendicitis  the  pain  is  more  likely  to  start  as  a  general  abdominal  pain, 
the  point  of  greatest  tenderness  and  the  inflammatory  mass,  if  there  is  one, 
being  in  the  appendix  region  instead  of  in  the  tubal  region.  In  appendicitis 
also  there  is  frequently  a  history  of  stomach  or  bowel  disturbance  preceding 
or  associated  with  the  attack  of  pain,  while  in  salpingitis  there  is  usually  a 
history  of  uterine  disturbance — dysmenorrhea,  prolonged  menstruation,  vagi- 
nal discharge  and  other  indications  of  a  previous  or  coincident  uterine  dis- 
ease. In  girls  and  in  unmarried  women  an  attack  of  inflammation  low  in  the 
right  side  is  much  more  likely  to  be  appendicitis  than  salpingitis.  In  some 
patients  both  structures  are  involved. 

In  all  right-sided  inflammations  keep  in  mind  appendicitis.  One  having  his 
mind  too  intent  on  pelvic  disease  may  overlook  this.  This  fact  is  very  well 
illustrated  by  a  case  in  which  I  was  called  in  consultation  by  a  physician  in 
this  city.  A  few  days  before,  the  physician  had  operated  for  laceration  of  the 
cer^dx.  Following  the  operation  the  patient  developed  pain  in  the  lower  abdo- 
men and  rapid  pulse,  and  nausea  and  fever.  The  symptoms  were  persistent 
and  progressive,  and  in  three  days  the  patient's  condition  became  alarming. 
Fearing  acute  pelvic  inflammation  from  infection  at  the  site  of  operation,  he 
asked  me  to  see  the  patient.  Examination  showed  the  cervical  wound  to  be 
in  good  condition  and  I  could  find  nothing  in  the  immediate  vicinity  of  the 
uterus  to  account  for  the  serious  symptoms.  But  on  searching  further  I  found 
the  patient  had  appendicitis,  with  peritonitis.  The  vomiting  and  intra-abdomi- 
nal disturbance  following  anesthesia  had  evidently  stirred  to  renewed  activity 
an  old  focus  of  inflammation  about  the  appendix.  The  patient  had  general 
peritonitis  at  the  time  I  saw  her  and  she  died  before  the  consent  of  her  people 
to  an  operation  could  be  secured. 

In  the  case  of  a  tumor  which  is  gang'renous  from  twisted  pedicle,  the  tumor 
has  existed  a  long  time,  and  one  can  usually  get  a  history  of  pelvic  disturbance 
caused  by  it,  and  in  some  cases  a  clear  history  of  a  tumor  can  be  obtained. 
When  the  turning  of  the  tumor  with  torsion  of  its  pedicle  takes  place,  that 
causes  a  sudden  onset  of  serious  symptoms — severe  pain,  extending  more  or 
less  throughout  the  abdomen,  and  symptoms  of  shock.  Later,  as  the  tumor 
begins  to  degenerate  on  account  of  the  cessation  of  its  blood  supply,  local 
peritonitis  comes  on,  causing  fever.  The  local  peritonitis  may  spread  and  be- 
come general  peritonitis,  and  at  this  stage  the  origin  of  the  trouble  is  much 
obscured.  Absence  of  evidence  of  infected  endometritis  is  another  important 
point  in  the  differential  diagnosis  of  this  condition  from  ordinary  pelvic  in- 
flammation, as  is  also  the  absence  of  fever  at  the  onset  of  the  trouble  and  for 
several  hours  afterward. 

A  suppurating-  tumor  is  usually  a  dermoid  cyst,  connected  with  the  ovary, 
and  lienr-e  gives  rise  to  a  mass  in  the  same  region  in  which  an  inflammatory 
mass  from  salpingitis  would  be  found.    When  suppuration  takes  place  in  an 


704  ACUTE  PELVIC  INFLAMMATION  ».  -^ 

1 
<i. 

ovarian  dermoid,  there  is  resulting  local  peritonitis,  with  fixation  of  the  mLSS 
by  adhesions.  The  fever  and  pelvic  pain  and  marked  tenderness  on  examina- 
tion all  tend  to  further  confusion  with  ordinary  pelvic  inflammation,  making; 
the  differential  diagnosis  often  very  difficult  and  sometimes  impossible.  If 
the  patient  is  a  girl,  or  a  woman  who  has  rffever  been  pregnant  nor  had  an;/ 
uterine  infection,  the  probability  is  in  favor~o|  dermoid  tumor  and  against 
salpingitis.  Two  other  points  in  favor  of  the  mass  being  a  dermoid  tumor 
are  (1)  a  history  of  pelvic  disturbance,  pointing  to  the  existence  of  a  tumor 
before  the  acute  symptoms  developed,  and  (2)^  the  absence  of  vaginal  dis- 
charge and  other  evidences  of  uterine  infection.; 

Necrosis  or  suppuration  within  a  uterine  fibroid  presents  the  evidences  of 
inflammation  added  to  evidences  (past  and  present)  of  a  fibroid  tumor. 

TREATMENT. 

In  the  treatment  of  acute  pelvic  inflammation  (acute  salpingitis,  acute 
oophoritis,  acute  pelvic  peritonitis,  acute  pelvic  cellulitis,  and  all  combina- 
tions of  these  lesions),  there  are  employed  certain  measures  that  may  be  called 
general  measures,  because  they  are  applicable  to  all  cases.  There  are  em- 
ployed also  other  measures  that  may  be  called  special  measures,  because  they 
are  applicable  to  special  conditions  only. 

GENERAL   MEASURES. 

The  general  measures,  indicated  in  the  treatment  of  practically  all  cases 
of  acute  pelvic  inflammation,  are  as  follows : 

1.  Rest.  Keep  the  patient  in  bed.  If  the  inflammation  is  severe,  she  should 
use  the  bed-pan  and  should  not  be  permitted  to  get  up  to  a  vessel  beside  the 
bed. 

2.  Laxatives.  The  patient  should  have  one  or  two  good  bowel  movements 
daily. 

3.  Hot  vaginal  douches  every  six  to  twelve  hours,  the  frequency  depending 
on  the  severity  of  the  inflammation. 

4.  Applications  to  the  Lower  Abdomen.  The  hot  applications  are  usually 
most  effective  in  relieving  pain.  In  exceptional  cases  the  cold  applications 
give  more  relief. 

5.  Sedatives.  If  the  pain  is  persistent  in  spite  of  the  measures  already  men- 
tioned,  mild  sedatives  should  be  used,  such  as  the  bromides  or  preparations 
containing  viburum  prunifolium.  Avoid  morphine  unless  the  pain  is  so  severe 
as  to  make  its  use  imperative,  for  it  disturbs  the  stomach,  checks  the  secre- 
tions and,  in  addition,  masks  the  pain  to  such  an  extent  as  to  interfere  with 
our  knowledge  of  the  progress  of  the  disease.  The  coal-tar  antipyretics  are 
also  usually  best  avoided  for  the  reason  that  they  mask  the  fever.  The  pain 
and  the  fever  are  two  important  guides  as  to  the  progress  of  the  inflammation, 
and  hence  should  not  be  masked  more  than  necessary.  If  there  is  mucli  fever, 
cool  sponging  will  give  comfort  and  reduce  the  temperature  and  stimulate 


TREATMENT 


705 


the  patient,  ami  its  eft'ect  can  be  more  accurately  gauged  than  that  of  internal 
antipyretics.  If  there  is  much  pain,  of  course  sedatives  must  be  given  in  suf- 
ficient quantity  to  give  rest.  Codeine  johosphate  in  1/2  gr.  to  %  gr.  doses  dis- 
turbs the  stomach  less  than  morphia  and  usually  gives  relief.  If  not  sufficient, 
tiien  morpliia  "will  be  necessary.  Whenever  sedatives  or  antipyretics  are  given, 
their  etfect  must  l)e  allowed  for  in  reckoning  the  extent  or  progress  of  the 
infllanmiation. 

SPECIAL    IMEASURES. 

The  special  measures,  indicated  in  certain  eases  of  acute  pelvic  inflamma- 
tion, are  most  conveniently  presented  by  stating  the  particular  conditions  for 
which  they  are  used; 

1.  If  the  infection  has  followed  labor  or  abortion,  see  that  the  interior  of 


Fig.  633.  Instruments  for  Opening  Pelvic  Abscess;  a,  self-retaining  speculum;  b,  perineal  retractor;  c, 
vaginal  dressing-forceps;  d,  uterine  tenaculum-forceps;  e,  two  long  artery-forceps;  f,  long,  curved,  blunt  scis- 
sors; g,  long,  curved,  sharp-pointed  scissors;  h,  needle  holder;  i,  needle  and  Ugature,  for  use  in  case  of  unusual 
hemorrhage;  j,  drainage  tube  with  cross-piece. 

the  uterus  is  clean.   This  will  usually  necessitate  exploration  of  the  interior  of 
the  uterus  with  the  finger  or  curet  (see  page  96). 

2.  If  the  infection  has  taken  place  through  an  operation  wound  of  the  cer- 
vix, remove  the  sutures  so  as  to  give  free  drainage  to  the  inflamed  area. 

3.  If  a  collection  of  pus  can  be  felt  low  in  the  pelvis,  open  and  drain  it  by 
vaginal  incision.  It  requires  care  to  open  a  deeply  placed  pelvic  abscess 
widely  and  safely,  particularly  if  the  pocket  of  pus  is  small.  The  rectum, 
uterus,  uterine  vessels,  ureter  or  bladder  may  be  injured,  or  the  abscess  may 
not  be  opened  and  drained  thoroughly  enough  to  etfect  a  cure.  The  instru- 
ments required  are  shown  in  Fig.  633. 

The  steps  in  the  operation  are  as  follows : 

a.  Examination  Under  Anesthesia. — After  the  patient  is  anesthetized  and 
the  vagina  thoroughly  cleansed,  make  a  bimanual  examination  to  determine 


706 


ACUTE  PELVIC  INFLAMMATION 


the  size  and  relations  of  the  inflammatory  mass  and  what  portion  of  it  is 
fluctuating.  Determine  also  whether  or  not  the  corpus  uteri  is  forward  and 
hence  out  of  the  way  of  the  operative  work. 

b.  Incision  Through  Vaginal  Wall. — Introduce  the  self-retaining  speculum 
(Fig.  633)  or  a  simple  perineal  retractor,  swab  out  the  vagina  again  with  an 
antiseptic  solution,  catch  the  posterior  lip  of  the  cervix  with  a  tenaculum 
forceps  and  raise  the  cervix  so  as  to  expose  the  posterior  vaginal  vault.  Now, 
with  a  long  forceps  (Fig.  633-e),  take  firm  hold  of  the  posterior  vaginal  wall 


Fig.  6.34.     Incision  Through  Vaginal  Wall.     The  retractor  has  been  introduced,  the  cenix  caught  with  a 
tenaculum-forceps,  and  the  vaginal  wall  chpped  through  just  back  of  the  cervix. 

a  short  distance  back  of  the  cervix  and  then  Avith  a  scissors  or  knife  clip 
through  the  vaginal  mucosa;  between  the  forceps  and  the  cervix.  I  usually 
use  the  same  blunt  curved  uterine  scissors  with  which  the  subsequent  dis- 
section is  made.  By  a  little  traction  on  the  forceps  a  ridge  of  mucosa  is  raised 
which  is  easily  clipped  through  with  tlie  scissors.  Th€  opening  is  then 
lengthened  to  each  side,  curving  slightly  around  the  cervix,  until  it  is  an  inch 
to  an  inch  and  a  half  long  (Fig.  641).  This  gives  an  opening  into  the  con- 
nective tissue  back  of  the  cervix,  as  sliown  in  Fig.  634. 

c.  Blunt  Dissection  Through  Connective  Tissue. — This  is  most  safely  and 


OPENING  PELVIC  ABSCESS 


707 


conveniently  accomplished  by  the  sense  of  touch  alone.  The  specnlum,  or 
perineal  retractor,  is  removed  and  two  fingers  are  introduced  into  the  vagina, 
one  of  the  fingers  being  carried  into  the  wound  back  of  cervix.  With  this 
linger  blunt  dissection  is  made  upward  tlirougli  the  connective  tissue,  keeping 
close  to  the  wall  of  the  cervix,  Avhich  is  distinguished  by  its  greater  hardness. 
Tliis  dissection  is  facilitated  by  introducing  the  closed  blunt  scissors  some  dis- 


Fig.  635.  Blunt  Dissection  Through  Connective  Tissue.  The  retractor  has  been  removed  to  permit  the 
fingers  to  be  introduced  into  the  vaginal  incision,  and  dissection  is  now  being  made  through  the  connective 
tissue  with  fingers  and  blunt  sci.s.sors,  as  described  in  the  text.  The  arrows  show  the  direction  of  the  dissec- 
tion (between  abscess  and  uterus  and  not  between  abscess  and  rectum),  and  each  arrow  may  be  taken  to  repre- 
sent a  forward  thrust  of  the  blunt  scissors  beyond  the  end  of  the  finger. 


tanee  ahead  of  the  finger  as  shown  in  Fig.  635,  and  then  opening  the  scissors 
widely.  The  finger  is  introduced  into  the  opening  thus  made  in  the  connective 
tissue,  and  the  scissors  are  again  introduced  beyond  tlie  finger  and  opened 
widely.  In  this  way  a  wide  tract  may  be  made  rapidly  through  the  connective 
tissue,  and  it  may  be  made  safely,  provided  the  operator  keeps  close  to  the 
cervix  as  indicated  in  Fig.  635.  Each  arrow  in  this  illustration  may  be  taken 
to  represent  a  forward  thrust  of  the  blunt    scissors    beyond   the  end  of   the 


708 


ACUTE  PELVIC  INFLAMMATION 


finger.  Notice  that  the  direction  of  the  dissection  carries  it  between  the  uterus 
and  the  abscess  instead  of  between  the  rectum  and  the  abscess,  and  thus  the 
danger  of  tearing  into  the  rectum  is  avoided.  On  the  other  hand,  the  dissec- 
tion must  not  be  carried  into  the  cervix  uteri.  Involvement  of  the  tough  tissue 
of  the  cervical  wall  is  indicated  by  the  blunt  dissection  becoming  very  difficult 
while  still  some  distance  from  the  abscess. 

d.  Puncturing  the  Abscess  Wall. — When  the  wall  of  the  abscess  is  reached, 


Fig.  6.36.     Puncturing  the  Ab.scess  Wiill.     The  .sharp-pointed  .scissor.s  have  been  introduced  into  the  mass 
under  the  guidance  of  the  finger,  and  then  opened  widely. 

further  advance  by  blunt  dissection  becomes  very  difficult  or  impossible.  This 
wall  of  dense  infiltration  blocking  further  advance  is  especially  marked  in  a 
long-standing  abscess,  but  it  is  present  in  acute  abscesses  also  to  a  considerable 
extent.  The  blunt  scissors  are  now  exchanged  for  the  sharp-pointed  scissors 
(Fig.  633-g),  and  with  these  the  puncture  is  made  into  the  center  of  the  in- 
flammatory mass.    Care  must  be  taken  to  make  sure  that  the  puncture  will 


OPENING  PELVIC  ABSCESS 


709 


not  extend  into  the  rectum.  A  hard  i'ecal  mass  in  the  rectum  may  he  mistaken 
for  a  portion  of  the  inflammatory  mass,  or  a  gas-distended  part  of  the  rectum 
iiKiy  simulate  the  soft,  ehistic  feel  of  a  fluctuating  nuiss,  or  a  collapsed  pocket 
of  flic  rectum  in;iy  project  hetween  the  vaginal  vault  and  the  a])scess.  In  Fig. 
{i'M  this  dangerous  i)i-()xiinity  of  the  rectal  wall  to  the  operative  tract  is  well 
shown,    if  the  line  of  blunt  dissection  is  kept  close  to  the  uterus,  the  abscess 


Fig.  6.37.  Drainage  Tube  in  Place.  The  cross-piece  is  to  prevent  the  tube  slipping  out.  The  tube  is  cut  off 
about  midway  of  the  vagina.  The  gauze  packing  e.xtends  into  the  connective  tissue  area  about  the  tube,  but 
not  into  the  abscess  cavity. 

wall  is  reached  close  to  the  uterus,  with  a  considerable  part  of  the  abscess 
lying  hetween  the  point  of  puncture  and  the  rectum,  as  shown  in  Fig.  635. 
Should  there  be  any  doubt  about  this,  leave  the  scissors  in  the  tract  and,  with 
gloved  fingers,  make  an  examination  per  rectum.  This  examination  gives  a 
clear  idea  of  the  amount  of  tissue  between  the  point  of  intended  puncture  (in- 
dicated by  the  end  of  the  scissors)  and  the  nearest  portion  of  the  rectal  wall. 


710 


ACUTE  PELVIC  INFLAMMATION 


After  the  curved,  sharp-pointed  scissors  have  been  pushed  into  the  center  of 
the  mass,  they  are  opened  widely  (Fig.  636)  and  then  withdrawn  while  still 
wide  open.  This  makes  a  large  tract  into  the  abscess.  One  or  two  fingers  are 
then  introduced  into  the  cavity  and  its  wall  explored  for  secondary  pus 
pockets.  If  a  fluctuating  area  is  found,  it  may  be  opened  by  the  finger,  dress- 
ing forceps  or  scissors,  care  being  taken  to  avoid  wounding  the  rectum  or 
mistaking  an  adherent  knuckle  of  intestine  for  a  fluctuating  pus  pocket. 
While  an  adherent  loop  of  intestine  may  feel  soft  and  elastic,  it  never  presents 


Fig.  038.  Showing  how  to  arrange  a  Drainage  Tube  with  a  small  cross-piece  at  the  end  to  keep  tlic  tube 
from  shpping  out  of  the  cavity.  Tt5  introduce  the  tube,  the  cross-piece  is  turned  up  on  eacli  side  and  the  cml 
of  the  tube  is  grasped  with  a  forceps,  as  shown  to  the  right  of  the  illustration. 


the  tense  fluctuation  and  resistance  of  a  pus  pocket,  unless  obstructed.  In  this 
palpation  of  the  interior  of  the  abscess  cavity,  all  manipulation  should  l)e  made 
gently,  so  as  not  to  break  through  the  protecting  roof  of  exudate. 

e.  Drainage. — After  all  pus  pockets  are  opened,  introduce  a  good-sized 
drainage  tube  into  the  abscess  cavity  (Fig.  637).  Swab  out  the  vagina  and 
pack  it  lightly  witli  antiseptic  gauze.  The  upper  end  of  tlic  gauze  sliould  be 
packed  rather  fii'iiily  iiilo  tlie  connective  tissue  about  1he  lube,  so  as  lo  stop 
any  bleeding  there.  The  gauze  is  to  be  packed  only  a  short  distance  into  the 
wound,  so  that  it  will  not  pull  out  the  tube  when  it  is  removed,  for  the  rubber 
tube  is  to  be  left  in  place  iiulil  the  cavity  is  nearly  obliterated  by  granulation, 
which  requires  two  to  six  weeks. 


DRAINAGE  IN  PELVIC  ABSCESS 


711 


The  draiuage  tulje  will  not  stay  iu  place  without  some  special  device.  A 
very  conveuient  expedient  is  to  i.itroduce  a  short  piece  of  a  smaller  tube  cross- 
wise through  holes  cut  near  the  end  of  the  main  tube  (Fig.  638).    This  drain- 


Fig.  G39.     Another  method  of  arranging  a  cross-piece  on  the  end  of  a  Drainage  Tube  to  keep  the  tube  from 
slipping  out  of  tlie  cavity.     (Reed — Text-book  of  Gynecology .) 

age-tube  is  introduced  into  the  abscess    cavity    by  grasping    it  with  a  long 
forceps  as  shown  in  the  illustration.    When  in  place,  the  forceps  are  removed 


Fig.  640.     The  Drainage  Tube  in  Place  in  a  Pehic  Abscess  Ca^-ity.     {Reed— Text-hook  of  Gynrco'oyy.)     , 

and  the  cross-piece  resumes  its  original  position,  and  thus  prevents  the  tube 
slipping  out  of  the  cavity.  When  it  is  desired  to  remove  the  tube,  slight  trac- 
tion causes  the  ends  of  the  cross  piece  to   fold  up,  and   the  tube   is  removed 


712  ACUTE  PELVIC  INFLAMMATION 

with  but  little  pain.  Another  method  of  forming  a  cross-piece  on  the  tube  is 
shown  in  Fig.  639,  and  such  a  tube  is  shown  in  place  in  Fig.  640.  After  the 
tube  is  in  place,  its  lower  end  is  cut  off  at  about  the  middle  of  the  vagina  and 
the  vaginal  gauze  packing  is  distributed  around  it.  If  the  tube  is  allowed  to 
extend  outside  the  vaginal  entrance,  it  causes  more  or  less  irritation  of  the 
external  surfaces,  and  if  it  is  cut  too  short  it  may  slip  up  into  the  abscess 
cavity  and  be  lost. 

Errors  to  Avoid.  One  error  to  avoid  is  irrigation  of  the  cavity.  The  free 
opening  of  the  abscess  relieves  the  tension,  and  this,  with  the  subsequent 
drainage,  is  all  that  is  required.  Furthermore,  if  a  stream  of  fluid  is  run  into 
the  cavity,  it  may  break  through  some  weak  place  in  the  protecting  wall  and 
cause  infection  of  the  general  peritoneal  cavity.  Irrigation,  therefore,  is  not 
only  unnecessary,  but  dangerous,  and  may  cause  fatal  peritonitis  in  a  case 
that  would  have  recovered  promptly  under  simple  drainage. 

Another  error  to  avoid  is  dependence  on  gauze  drainage.  A  considerable 
proportion  of  failures  and  secondary  operations  are  due  to  this.  When  there 
is  a  distinct  abscess  cavity,  there  will  necessarily  be  discharge  for  some  time, 
and  this  discharge  should  find  ready  exit  through  tube  drains.  Gauze  packing 
is  very  good  for  checking  bleeding  or  for  holding  the  tract  open  for  a  few 
days,  but  it  is  not  satisfactory  when  prolonged  drainage  is  necessary,  and  pro- 
longed drainage  is  necessary  in  practically  all  cases  where  a  distinctly  walled 
abscess  has  formed.  In  the  crowded  and  contracting  tissues  of  the  pelvis,  tube 
drainage  is  the  only  kind  that  will  keep  the  drainage  tract  open  satisfactorily 
and  conveniently  for  the  length  of  time  required  for  a  large  cavity  to  become 
obliterated  by  granulation.  And  the  best  time  to  place  this  tube  drain  satis- 
factorily is  when  the  patient  is  under  the  anesthetic  and  the  abscess  just 
opened. 

Variations.  In  a  case  of  tubal  abscess  where  the  pus  has  not  yet  escaped 
from  the  Fallopian  tube,  the  cul-de-sac  of  Douglas  is  opened  before  the  ab- 
scess proper  (tube  wall)  is  reached.  The  cul-de-sac  may  or  may  not  be  shut 
off  from  the  general  peritoneal  cavity  by  adhesions.  In  some  such  cases  a 
small  amount  of  serous  fluid  escapes  when  the  cul-de-sac  is  opened.  Exploring 
this  non-purulent  cavity,  the  finger  encounters  the  distended,  fluctuating  tube, 
which  is  then  opened,  with  a  resulting  free  discharge  of  pus.  Two  points  of 
importance  in  such  a  case  are :  first,  to  make  a  free  opening  in  the  wall  of  the 
distended  tube,  and,  second,  to  place  the  end  of  the  drainage  tube  inside  the 
affected  tube  and  not  simply  in  the  cul-de-sac. 

In  draining  a  broad  ligament  abscess,  avoid  opening  the  peritoneal  cul-de- 
sac.  Such  opening. is  unnecessary  and  is  dangerous,  for  the  uninfected 
cul-de-sac  is  not  likely  to  be  walled  off  from  the  general  peritoneal  cavity.  In 
operating  in  a  case  where  the  inflammatory  mass  is  situated  laterally,  the 
vaginal  wall  is  cut  through  as  before,  and  then  the  dissection  is  directed  later- 
ally between  the  layers  of  the  broad  ligament,  as  indicated  in  Fig.  641.  In 
this  way  a  collection  of  pus  situated  even  in  the  upper  part  of  the  broad  liga- 
ment may  be  drained  freely  without  opening  the  peritoneal  cavity. 


AFTER-TREATMENT  IN  PELVIC  ABSCESS 


713 


Tn  an  acute  inflammatory  mass  withont  pns  it  may  in  certain  cases  be  ad- 
visable to  drain.  In  a  considerable  proportion  of  inflammatory  masses  it  is 
impossible  to  say  positively  before  operation  whether  or  not  there  is  a  pocket 
of  pns  in  the  mass.  If  the  general  symptoms  are  threatening  and  the  mass  is 
increasing  in  size  and  tenderness,  drainage  is  advisable— on  the  general  sur- 
gical principle  of  immediate  drainage  of  an  acute  infected  focus  that  nature 
is  failing  to  limit.  In  such  a  case  the  steps  are  the  same  as  for  a  distinct  ab- 
scess—viz., blunt  dissection  through  the  connective  tissue,  puncture  to  the 
center  of  the  mass  with  sharp-pointed  scissors  and  enlargement  of  the  tract  by 
withdrawing  the  scissors  wide  open.  The  interior  of  the  mass  is  then  palpated 
with  one  or  two  fingers  and  perhaps  opened  further  in  various  directions.  If 
no  pus  is  found,  the  cavity  is  packed  lightly  with  gauze.  As  there  is  no  distinct 
pus  cavity,  there  is  no  indication  for  tube  drainage.  However,  if  when  the 
gauze  is  removed  after  two  or  three  days  a  free  purulent  discharge  is  present 
(due  to  an  adjacent  pus  pocket  opening  into  the  cavity  or  to  the  advance- 


Fig.  641.  Opening  Lateral  Absces.ses.  After  the  vaginal  wall  is  cut  through,  the  blunt  dissection  is  directed 
laterally  into  the  broad  Ugament,  as  indicated  by  the  lateral  arrows.  In  this  way  opening  of  the  peritoneal 
cavity  may  be  avoided. 

ment  of  the  inflammatory  process  to  the  point  of  suppuration),  then  a  small 
drainage  tube  with  cross-piece  should  be  introduced  at  the  time  the  gauze  is 
removed.  If  no  pus  is  present,  no  tube  drain  is  required — simply  vaginal 
douches,  with  or  without  light  gauze-packing  of  the  tract,  as  preferred.  I 
have  seen,  in  a  number  of  instances,  marked  relief  from  pain  and  rapid  resolu- 
tion follow  this  puncture  and  drainage  of  an  acute  inflammatory  mass  with- 
out distinct  pus  formation. 

After-treatment.  In  the  after-treatment  of  an  opened  pelvic  abscess  the 
tAvo  important  points  are  (1)  continued  free  drainage  until  the  cavity  has  been 
practically  obliterated  by  granulation,  and  (2)  avoidance  of  unnecessary  irri- 
tation, such  as  repeated  packing  or  probing  of  the  tract,  or  frequent  syringing 
of  the  abscess  cavity. 

Neglect  of  the  first  point  is  the  cause  of  the  failure  in  a  large  proportion  of 
the  cases  where  the  abscess  reforms  and  requires  secondary  operation — that 


714  ACUTE  PELVIC  INFLAMMATION 

is,  when  the  case  has  been  well  chosen  and  is  really  suitable  for  vaginal  drain- 
age. The  neglect  of  the  second  point  causes  much  unnecessarj^  pain  and  irrita- 
tion by  repeated  probing  and  packing  of  the  suppurating  tract,  and  also 
contributes  to  failure  by  early  removal  of  the  well-placed  rubber  drainage 
tube,  which  is  the  only  efficient  method  of  continued  drainage  in  this  situa- 
tion. 

The  gauze  in  the  vagina  is  removed  in  one  or  two  days  and  after  that  an 
antiseptic  vaginal  douche  is  given  one  to  three  times  daily,  the  frequency  de- 
pending on  the  amount  of  discharge.  The  patient  is  kept  in  bed  for  a  week, 
and  after  that,  if  there  is  no  pain  nor  fever,  she  is  allowed  to  be  up  and  about. 
If  the  tube  stops  up  at  any  time,  it  may  be  cleared  out  by  iujectiiig  some 
hydrogen  peroxide  into  it.  If  this  does  not  clear  it,  it  is  probably  stopped  by  a 
slough  or  fibrinous  mass.  Remove  the  tube  and,  after  clearing  it  thoroughly, 
reintroduce  it  or  a  smaller  one.  For  changing  the  tube  or  for  any  manipula- 
tion about  the  opening  back  of  the  cervix,  the  Sims  posture  is  more  con- 
venient than  the  dorsal  posture  (see  page  86). 

The  tube  should  be  left  in  place  as  long  as  there  is  a  cavity  to  discharge — 
varying  in  different  cases  from  two  to  six  weeks.  If  after  the  large  tube  has 
been  in  for  a  week  the  patient  complains  of  pain  on  bowel  movement  or  other 
pain  in  pelvis,  remove  the  tube  and  introduce  a  smaller  one.  As  the  abscess 
cavity  contracts,  it  is  necessary  to  reduce  the  size  of  the  tube  and  cross-piece 
sufficiently  to  prevent  pressure-ulceration  of  the  rectal  wall.  Continue  the 
douches  for  at  least  a  Aveek  after  tube  is  removed  and  all  discharge  has  ceased. 

4.  If  a  collection  of  pus,  or  a  mass  of  exudate  that  may  or  may  not  contain 
pus,  is  found  high  in  the  pelvis,  do  not  disturb  it  during  the  acute  attack  un- 
less the  patient's  life  is  threatened  by  the  severity  of  the  process.  Avoid 
abdominal  operation  in  the  primary  acute  attack  if  possible.  There  are  two 
reasons  for  this — first,  the  patient  may  recover  completely  under  the  minor 
measures  (rest,  laxatives,  hot  douches,  curettage),  and,  second,  if  extirpation 
of  the  mass  is  finally  necessary,  it  can  be  carried  out  later  with  much  less  dan- 
ger to  the  patient.  There  is  less  danger  later  because  collections  of  pus  in 
the  pelvis  become  less  virulent  after  a  time.  In  many  old  pelvic  abscesses  the 
bacteria  are  dead  and  the  pus  is  sterile,  and  extensive  contamination  of  the 
field  of  operation  fails  to  cause  peritonitis.  If,  on  the  other  hand,  the  opera- 
tion is  done  early  while  the  bacteria  are  still  virulent,  contamination  of  the 
field  is  very  likely  to  result  in  fatal  peritonitis. 

In  mentioning  the  fact  that  the  majority  of  inflammatory  masses  in  the 
pelvis  become  sterile  after  a  time,  attention  must  be  called  to  an  exceptional 
class — namely,  the  s-treptococcal  cases.  In  the  streptococcal  masses  automatic 
sterilization  or  attenuation  is  uncertain.  Though  sometimes  present,  its  occur- 
rence can  never  be  counted  on.  In  streptococcal  masses  the  1)acteria  have 
been  found  active  and  virulent  after  long  periods — even  years.  Consequently, 
in  these  cases  intraperitoneal  operation  is  never  safe.  The  persistence  of  viru- 
lence in  streptocoecal  cases,  how  to  recognize  them  before  operation,  Avhat  to 
do  for  them  when  operation  is  necessary,  and    other    points  of   interest  are 


VIRULENT   PELVIC   PERITONITIS 


715 


considered  in  detail   niidor  olironir'  infinniinatory  masses  in  tlie  pelvis    (see 
pages  751  to  754). 

In  acute  iniiaimiiatory  masses,  whether  streptococcal  or  gonococcal,  intra- 
peritoneal operation  is  to  be  avoided.  Those  abscesses  situated  high  are  the 
ones  now  under  consideration.  If  the  symptoms  are  urgent,  and  the  pocket  of 
pus  can  not  be  reached  and  drained  per  vaginam,  it  may  be  possible  to  drain 
it  extraperitoneally  by  operation  above  Poupart's  ligament.  This  is  entirely 
practical  Avhen  the  abscess  is  situated  in  the  broad  ligament  (as  most  strep- 
tococcal abscesses  are)  and  it  has  proven  a  life-saving  measure  in  several  in- 
stance's. The  route  followed  is  the  same  as  for  ligation  of  the  external  iliac 
artery.    In  all  but  exceptional  cases,  however,  an  abscess  in  any  part  of  the 


Fig.  642.  Vaginal  Section  for  .\cute  Pelvic  Inflammation,  showing  the  gauzing  packing  in  place.  (Kelly— 
Operative  Gynecologu) 

broad  ligament  can  be  reached  and  drained  satisfactorily  per  vaginam  by  any 
one  familiar  with  vaginal  work. 

5.  If  the  inflammation  takes  the  form  of  a  rapidly-spreading  peritonitis, 
Avith  little  or  no  limiting  exudate,  or  in  spite  of  limiting  exudate,  the  perito- 
neal cavity  should  be  opened  and  drained,  either  by  vaginal  section  or 
abdominal  section  or  both.  Such  cases  are  seen  principally  in  pelvic  inflam- 
mation following  labor  or  miscarriage  and  constitute  a  severe  type  of  puerperal 
sepsis.  The  inflammation  may  have  extended  directly  through  the  wall  of  the 
uterus  to  the  peritoneum,  or  first  to  the  Fallopian  tubes  and  from  there  to  the 
peritoneum.  In  either  case  there  is  a  rapidly  spreading  peritonitis  of  \drulent 
type  and  the  patient  is  in  a  desperate  condition.  There  are  two  methods  of 
dealing  with  these  cases ; 


716 


ACUTE  PELVIC  INFLAMMATION 


Vaginal  Section. — Open  into  the  pelvic  cavity  by  poi?terioi'  vaginal  section 
and  let  the  infected  peritoneal  fluid  run.  out.  Palpate  the  uterus  and  ap- 
pendages, and,  if  a  collection  of  pus  is  found,  evacuate  it.  Put  in  a  large  size 
rubber  drainage  tube  and  pack  the  pelvis  lightly  with  gauze,  letting  the  ends 
extend  out  into  the  vagina  (Figs.  642,  643).  "Washed  iodoform  gauze  has  been 
recommended  for  this  intraperitoneal  packing,  but  several  instances  of  iodo- 
form poisoning  from  absorption  have  been  reported.  It  is  safer  to  use  plain 
gauze  wrung  out  of  a  weak  bichloride  solution.  The  principal  effect  desired 
is  drainage  and  this  is  accomplished  by  the  rubber  tube.  The  gauze  packed  in 
the  wound  about  the  tube  checks  bleeding,  and  preserves  a  good  sized  cavity 
about  the  tube,  and  thus  drains  the  entire  pelvis  instead  of  a  small  sinus,  which 
might  be  all  that  would  remain  were  the  structures  allowed  to  collapse  about 


Fig.  643.     Vaginal  Section  for  Acute  Pelvic  Inflammation.     A  view  from  above,  showing  the  packing  in 
contact  with  the  inflamed  tube.s.     (Kelly — Operative  Gynecology.) 

the  tube  immediately  after  its  introduction.  Gauze  is  then  placed  in  the  vagina 
and  a  large  dressing  applied  over  the  vulva,  and  the  patient  put  to  bed.  The 
gauze  in  the  vagina  may  be  removed  in  twenty-four  hours,  the  vagina  cleansed, 
and  fresh  gauze  inserted  or  douches  given,  as  preferred.  The  gauze  in  the 
pelvis  should  be  left  in  place  from  two  to  four  days,  providing  there  is  good 
drainage  during  that  time.  When  it  is  removed,  reintroduce  the  rubber  drain- 
age tube  to  insure  good  drainage  and  keep  the  vaginal  wound  from  closing 
too  soon. 

Abdominal  Section. — Open  the  abdomen  l)y  incision  in  the  median  line  and 
make  free  drainage  with  a  glass  tube  to  the  depth  of  the  pelvis,  with  or  with- 
out removal  of  affected  tu])e  or  tubes,  as  seems  best  in  the  particular  case. 


TREATMENT  OF  ACUTE  SPREADING  PERITONITIS  717 

Of  tlie  tvro  methods  of  pelvic  drainage,  the  first  (vaginal  section)  is  the 
I)referal)le  one  in  the  majority  of  cases  of  acute  virulent  pelvic  peritonitis  if 
the  inflammation  is  still  confined  to  the  pelvis.  When  the  general  peritoneal 
cavity  is  not  involved,  vaginal  section  accomplishes  all  the  important  results 
that  can  be  accomplished  by  abdominal  section — the  emptying  of  pus  pockets 
and  free  drainage  of  the  infected  area — and  with  much  less  danger  to  the 
patient.  Of  course,  if  the  infection  has  already  extended  to  the  higher  por- 
tions of  the  peritoneal  cavity,  there  may  be  pockets  of  septic  fluid  in  the  cen- 
tral abdomen  which  can  not  be  evacuated  from  below.  Under  such  circum- 
stances abdominal  operation  is  usually  required,  either  alone  or  in  comlnna- 
tion  with  vaginal  drainage.  In  addition  to  drainage  of  the  infected  peritoneal 
cavity  by  vaginal  section  or  abdominal  section,  or  both,  there  are  certain  other 
measures  of  much  importance  in  acute  peritonitis — namely,  stomach  lavage  and 
withholding  nourishment  by  mouth  (to  prevent  injurious  intestinal  peristalsis), 
Fowler  posture  (for  drainage)  and  the  introduction  of  large  quantities  of 
normal  saline  solution  into  the  system  (to  strengthen  the  vital  organs  and  aid 
elimination). 

The  treatment  of  acute  spreading  peritonitis  of  virulent  type  has  under- 
gone a  radical  change  in  the  last  few  years,  and  with  remarkable  reduction  in 
the  mortality.  Formerly  eighty  to  ninety  per  cent  of  these  patients  were  lost. 
Now  eighty  to  ninety  percent  are  saved.  This  splendid  result  has  been  ob- 
tained by  a  more  intelligent  aiding  of  nature  in  the  limitation*  of  the  infective 
process  and  in  tha  elimination  of  the  infective  material.  In  order  to  bring 
out  the  essential  features  in  handling  these  cases  of  general  peritonitis,  or  of 
local  peritonitis  threatening  to  become  general,  it  is  necessary  to  say  a  few 
words  in  regard  to  nature's  efforts  at  caring  for  them.  The  process  is  best 
studied  where  a  ciuantity  of  infective  material  is  liberated  siiddenly  in  the 
peritoneal  cavity,  the  best  examples  of  which  are  seen  in  perforations  of  the 
intestinal  tract.  The  most  common  of  these  is  perforation  of  the  appendix. 
Hence,  the  great  advance  in  the  treatment  of  peritonitis  of  virulent  type  has 
been  made  largely  from  the  study  and  treatment  of  cases  of  perforative  appen- 
dicitis. In  tliis  study  it  has  been  established  that,  in  nature's  attempt  to  pro-, 
tect  the  system  from  the  infective  material,  there  are  three  important 
factors,  as  follows :  a.  A  wall  of  exudate  which  surrounds  the  infective  ma- 
terial, binding  together  the  adjacent  surfaces,  and  opposing  an  organic  barrier 
to  the  spread  of  the  infection,     b.  Immobilization  of  the  intestinal  coils,  which 


*This  limitation  of  the  infective  process  is  effected  byjthe  inflammatory  infiltration  and  exudate  and  ad- 
hesions. These  features  are  protective  and  constitute  nature's  method  of  combating  the  .spread  of  the  in- 
fection. The  protective  features  of  inflammation  have  been  strongly  emphasized  in  recent  years  by  a  number 
of  writers,  particularly  by  Dr.  Channing  W.  Barrett,  who  states  in  a  recent  article,  "Inflammation  is  not  the 
fire,  it  is  the  fire  department;  it  is  not  the  epidemic,  it  is  the  health  department;  it  is  not  the  army  of  invasion, 
it  is  the  army  of  defense."  However,  in  combating  the  old  idea  that  inflammation  was  wholly  a  destructive 
process,  I  see  no  reason  to  go  to  the  other  extreme  and  try  to  label  it  as  a  wholly  constructive  or  protective 
process  Peritonitis  (or  inflammation  in  any  other  situation)  is  a  complex  condition,  and  any  complete  con- 
ception of  it  must  include  both  the  invading  organisms  and  the  resisting  forces.  The  term  "peritonitis"  is 
used,  and  I  think  rightly  used,  by  clinicians  to  designate  the  conflict  between  these  opposing  forces  and  the 
usual  results  thereof.  To  use  the  simile  of  my  friend  above  quoted:  Inflammation  is  not  the  army  of  invasion, 
neither  is  it  the  army  of  defense — it  is  the  conflict  between  the  two.  In  one  case  it  is  a  short  sharp  local  fight, 
while  in  another  case  it  is  a  prolonged  conflict  along  a  far-flung  battle  line,  that  may  involve  the  whole  body. 


TREATMENT  OF  ACUTE  SPREADING  PERITONITIS  719 

gives  58  eases  witli  56  recoveries.  Other  operators  have  secured  nearly  as  good 
results  by  this  treatment,  so  that  it  is  now  very  generally  employed  with  the 
saving  of  many  patients.  A.  J.  Ochsner  has  rendered  valuable  service  by  em- 
phasizing the  necessity  of  intestinal  mobilization  by  ^Anthholding  all  food  and 
washing  out  the  stomach.  This  is  important  both  before  operation  and  after 
operation  until  the  process  is  well  localized.  Ochsner  laid  special  emphasis  on 
its  use  before  operation  and  in  certain  carefully  selected  cases,  instead  of 
operation  during  the  acute  stage.  This  last  recommendation,  of  using  it  to  the 
exclusion  of  operation  in  certain  desperate  cases,  is  a  questionable  one  at 
present.  When  this  treatment  was  first  proposed  as  a  substitute  for  immediate 
operation  in  the  carefully  selected  cases  belonging  to  that  fatal  class  generally 
recognized  as  "too  late  for  early  operation  and  too  early  for  late  operation," 
it  undoubtedly  saved  many  patients,  for  it  was  opposed  to  the  extensive  opera- 
tion and  general  irrigation  treatment  then  in  use,  which  gave  a  mortality  of 
80  to  90  per  cent.  By  absolute  rest  of  the  stomach  and  upper  bowel,  secured 
by  painstaking  attention  to  detail,  Ochsner  was  able  to  tide  the  patients  over 
the  critical  period  and  operate  later  with  a  reduction  of  the  mortality  to  one- 
fourth  what  it  was  formerly — i.  e.,  to  the  neighborhood  of  20  per  cent.  With 
the  substitution  of  simple  drainage,  however,  for  extensive  operation  in  these 
cases,  the  serious  objections  to  operation  (shock  and  mechanical  spread  of  the 
infection)  have  practically  disappeared  even  in  the  most  desperate  cases. 
When  the  patient  is  so  weak  that  general  anesthesia  is  not  ad^'isable,  the  sim- 
ple drainage  may  be  made  under  local  anesthesia  and  the  exit  of  infected 
material  through  this  vent  may  turn  the  tide  of  battle  to  the  sav^ing  of  the 
patient.  That  this  is  true  is  shown  conclusively,  I  think,  by  the  fact  that  ]\lur- 
phy,  employing  drainage  associated  with  other  less  important  features,  was 
able  to  save  56  out  of  a  series  of  58  cases — reduction  of  the  mortality  to  less 
than  4  per  cent. 

Associated  with  drainage,  stomach  washing  and  intestinal  rest  are  im- 
portant features,  both  before  and  after  operation.  In  fact,  some  insist  that 
the  splendid  results  which  attend  the  "Murphy  treatment"  are  due,  aside 
from  drainage,  almost  entirely  to  the  stomach  and  intestinal  rest  so  strongly 
emphasized  by  Ochsner.  In  a  recent  article,  G.  S.  Brown,  in  support  of  the 
contention,  reports  a  series  of  17  cases  of  diffuse  peritonitis  with  14  recover- 
ies, in  which  the  treatment  employed  was  drainage  by  operation  com1)ined 
with  the  antiperistaltic  regimen  of  Och.sner,  "without  the  use  of  the  ]\Iurphy- 
Fowler  features."  It  is  difficult  to  decide  certainly  as  to  the  relative  im- 
portance of  each  of  the  factors  wbich  enter  into  the  present  successful 
treatment  of  extensive  peritonitis.  There  are  several  reasons  for  this.  There 
are  certain  essential  teclmical  details  about  some  of  the  factors  that  are 
not  always  fully  comprehended  and  carried  out — hence  confidence  may  be 
lost  in  one  or  another  feature  of  the  treatment  simply  through  the  inefficiency 
of  the  one  wlio  employs  it.  Again,  physicians  differ  much  as  to  the  cases 
they  classify  under  "acute  diffuse  peritonitis,"  thus  causing  a  marked  differ- 
ence in  the  mortality  records..   Still  again,  the  combination  method  generally 


718  ACUTE  PELVIC  INFLAMMATION 

prevents  meehanical  spread  of  the  infectious  material,  such  as  would  neces- 
sarily take  place  in  the  presence  of  normal  intestinal  peristalsis.  This  im- 
mobilization of  the  intestinal  coils  is  formed  in  part  mechanically  by  !;he 
adhesions  forming  the  wall  of  limiting  exudate,  and  in  part  physiologically  by 
tlie  anorexia,  which  causes  very  little  food  to  be  taken,  and  by  the  vomiting, 
wliich  rejects  a  large  part  of  that  which  is  taken,  c.  Elimination — first  of  the 
toxins  through  the  kidneys  and  other  eliminative  organs,  and,  second,  of  the 
infectious  material  itself  througli  an  opening  to  the  external  surface  of  the 
body  or  into  some  hollow  organ. 

Such  in  brief  is  nature's  method  of  handling  these  cases.  The  rcNuits  vary 
with  the  virulence  of  the  infection,  the  vital  resistance  of  the  individual,  and 
the  efficiency  of  the  outside  help.  These  are  desperate  cases.  With  or  witliout 
outside  help,  the  patient's  life  hangs  in  the  balance,  and  every  move  that  is 
made  should  be  made  with  the  idea  of  aiding  nature  and  not  handicapping  her. 
Such  intelligent  assistance  can  be  given  only  by  a  Avell-balanced  consideration 
of  each  of  the  three  factors  above  mentioned.  One  or  another  of  these  factors 
has  at  various  times  been  given  undue  prominence  in  the  treatment.  The 
old  opium  treatment  considered  the  immobilization  and  the  exudate,  with 
practically  entire  neglect  of  elimination,  either  general  or  local.  The  later 
treatment  by  operation,  widespread  irrigation  and  mopping  of  peritoneal  sur- 
faces, and  extensive  drainage,  was  based  upon  an  exaggerated  idea  of  the 
importance  of  elimination  and  an  erroneous  idea  as  to  how  best  secure  the 
really  necessary  elimination.  This  method,  which  Avas  practiced  generally  a 
few  years  ago,  took  almost  no  account  of  any  factor  save  drainage. 

In  the  present  method  of  treating  such  spreading  peritonitis  the  wall  of 
exudate  is  preserved  as  far  as  possible  by  employing  simple  drainage  without 
irrigation  or  extensive  exploration,  or  any  other  manipulation,  except  that 
necessary  to  give  exit  to  the  infected  material  and  perhaps  remove  a  slough- 
ing structure  or  close  an  opening  into  the  intestinal  tract.  The  immobilization 
of  the  adjacent  intestinal  coils  is  favored  by  leaving  the  adhesions  and  by 
quieting  intestinal  peristalsis  through  withholding  all  food  for  a  few  days  and 
through  stomach  washings.  Elimination  is  secured  through  simple  drainage  of 
the  infected  site  and,  when  needed,  of  the  pelvic  peritoneal  pouch,  aided  by  the 
half-sitting  posture  (Fowler's  posture)  and  the  free  use  of  normal  saline  solu- 
tion, particularly  by  slow  continuous  rectal  absorption   (proctoclysis). 

This  combination  treatment  has  reduced  the  mortality  of  acute  general  peri- 
tonitis from  80  to  90  per  cent  to  10  per  cent,  and  even  below.  This  remark- 
able result  is  well  established  and  unquestioned.  However,  there  is  consider- 
able difference  of  opinion  as  to  the  relative  importance  of  different  factors 
in  the  treatment.  J.  B.  Murphy  was  the  first  to  arrest  the  attention  of  the 
profession  generally,  and  focus  it  on  this  subject,  by  the  report  in  1905  of  a 
series  of  29  cases. of  acute  general  peritonitis  with  28  recoveries.  IMurphy  laid 
stress  on  three  factors — viz.,  simple  drainage  (without  irrigation  or  other  ex- 
tensive intraperitoneal  disturbance),  the  Fowler  posture  and  proctoclysis.  A 
late  report  of  his  experience  (Surgery,  Gynecology  and  Obstetrics,  Feb.,  1910) 


720  ACUTE  PELVIC  INFLAMMATION 

employed,  while  contributing  to  splendid  results,  contributes  also  to  un- 
certainty as  to  the  relative  importance  of  the  various  features.  I  mention 
this  uncertainty,  not  to  discourage  the  use  of  the  combination  treatment,  but 
simply  to  call  attention  to  the  fact  that  there  is  probablj^  good  in  each  of 
the  features  and  that  it  is  not  wise  to  make  positive  statements  as  to  the 
exclusive  sufficiency  of  this  or  that  feature  until  we  have  acquired  more 
definite  knowledge  through  further  experience. 

The  combination  treatment  for  acute  spreading  peritonitis  which  I  consider 
best  is,  in  detail,  as  follows : 

a.  Withhold  all  Food  and  Cathartics  by  Mouth  and  Empty  the  Stomach 
With  a  Stomach-tube.  As  soon  as  an  acute  spreading  peritonitis  is  recognized 
arrangements  should  at  once  be  made  for  a  drainage  operation.  The  sooner 
the  infecting  material  is  given  an  external  exit,  the  better  will  be  the 
patient's  chance  for  recovery.  While  preparing  for  the  operation,  however, 
and  also  subsequent  to  operation,  this  antiperistaltic  treatment  is  indicated. 
There  are  certain  details  that  must  be  carried  out  to  the  letter  to  secure 
the  best  results.  No  food  of  any  kind  is  to  be  given  by  mouth,  not  even  a 
teaspoonful  of  liquid  nourishment.  The  least  nourishment  taken  into  the 
stomach  and  passing  into  the  intestine  will  excite  intestinal  peristalsis  and 
defeat  the  purpose  of  the  treatment.  Also,  the  food  already  in  the  stomach 
will  excite  peristalsis  unless  removed.  Very  often  considerable  has  been 
removed  by  vomiting,  but  vomiting  is  not  to  be  depended  upon.  Though 
the  patient  has  vomited  several  times,  still  there  may  be  enough  food  remnants 
remaining  to  pass  into  the  intestine  and  excite  it  to  action.  In  fact  the 
persistence  of  vomiting  indicates  the  presence  of  some  irritating  material  in 
the  stomach.  Consequently,  the  stomach-tube  should  be  used  to  insure, 
thorough  emptying  of  the  stomach  in  every  case,  except  where  there  is  some 
special  contra-indication  to  its  use  (ulcer  of  stomach,  carcinoma,  child  too 
young,  etc.) 

The  gastric  lavage  may  be  simplified  and  made  less  disagreeable  by  attention 
to  details.  Turn  the  patient  well  over  on  the  side,  preferably  the  side  in 
which  the  inflammatory  process  is  located.  Spray  the  pharynx  with  a  four 
per  cent,  solution  of  cocaine,  spray  it  three  or  four  times  in  the  course  of 
five  minutes,  directing  the  patient  to  hold  the  solution  in  the  pharynx  for  a 
few  seconds  and  then  expectorate  it.  The  stomach-tube  should  be  of  good 
size,  with  an  opening  at  the  side  as  well  as  at  the  end.  Cool  it  in  ice  water 
and  introduce  it  without  special  lubrication — simply  wet  with  the  ice  water. 
Direct  the  patient  to  assist  the  passage  of  the  tube  along  the  oesophagus  by 
swallowing  repeatedly.  Gastric  lavage  has  come  into  such  general  use  in 
the  treatment  of  post-operative  gastric-dilatation  and  other  conditions,  and 
is  so  necessary,  that  a  pliysician  having  anything  to  do  witli  an  abdominal 
case  should  know  how  to  introduce  the  stomach  tube  without  disturl)ing  the 
patient  overmuch.  When  the  tube  has  reached  the  stomach,  siphon  out  the 
contents.  Then  introduce  warm  normal  saline  solution  and  siphon  it  out 
repeatedly  until  it  returns  clear.  Use  a  pint  and  more  if  necessary,  and  at 
the  end  empty  the  stomach  as  nearly  as  possible. 


TREATMENT  OF  ACUTE  SPREADING   PERITONITIS  721 

This  gastric  lavage  makes  the  patient  more  comfortable.  It  gives  the 
stomach  rest  from  irritating  decomposing  material,  diminishes  the  peristalsis, 
diminishes  the  distention,  and  stops  the  vomiting,  which  in  itself  does  harm 
by  disturbing  the  limiting  adhesions.  The  one  stomach  washing  may  be  all 
that  is  needed.  If  the  vomiting  recurs,  however,  lavage  is  again  indicated, 
for  it  means  usually  that  reverse  peristalsis  has  brought  material  from  the 
upper  intestine  into  the  stomach,  and  this  should  be  removed  by  the  tube 
as  was  the  first.  In  nature's  method  of  localizing  the  infection,  inhibition  of 
peristalsis  in  adjacent  intestinal  coils  (temporary  intestinal  paralysis)  is  an 
important  factor.  If  there  is  food  in  the  upper  intestine,  it  excites  peristalsis. 
Now,  tliis  normal  peristalsis  and  onward  progress  being  interfered  by  the 
immobilization  of  certain  intestinal  coils,  there  is  reverse  peristalsis,  which 
carries  the  irritating  material  back  into  the  stomach,  where  it  is  partially 
thrown  off  by  vomiting.  The  continued  administration  of  food,  and  especially 
of  cathartics,  aggravates  the  peristalsis  and  reverse  peristalsis,  adding  much 
to  the  patient's  danger  and  discomfort.  Two  or  three  extra  stomach  wash- 
ings at  intervals  of  several  hours  may  be  necessary  before  complete  rest  of 
the  stomach  and  boAvel  is  secured.  This  complete  emptying  of  the  stomach 
and  upper  bowel  has  a  very  decided  effect  within  twelve  to  twenty-four 
liours.  There  is  cessation  of  the  vomiting  and  diminution  of  the  nausea, 
distention,  pain  and  fever.  The  pulse  and  respiration  improve,  and  the  dis- 
comfort and  threatening  symptoms  disappear  to  a  large  extent.  Ochsner 
remarks,  ''Usually  the  improvement  is  so  rapid  that  one  is  tempted  to  spoil 
everything  by  giving  nourishment  by  mouth,  because  the  patient's  condition 
does  not  seem  serious  enough  to  warrant  such  severe  deprivation  measures." 
This  treatment  is  to  be  used  while  arrangements  are  being  made  for  operation 
and  it  is  to  be  used  also  after  operation,  along  with  the  Fowler  posture, 
proctoclysis  and  rectal  nourishment  until  the  inflammatory  process  is  well 
localized  and  stomach  feeding  may  be  safely  resumed. 

b.  Drainage  of  the  Infected  Area,  with  the  Least  Possible  Intraperitoneal 
Disturbance.  This  should  be  carried  out  as  soon  as  possible.  There  should 
be  no  irrigation  and  no  breaking  of  adhesions,  beyond  that  absolutely  neces- 
sary to  drain  the  pus  pocket  or  pockets  and,  in  certain  exceptional  cases,  to 
remove  sloughing  tissue  or  close  a  hole  in  the  intestinal  wall.  The  anesthesia 
should  be  of  the  shortest  possible  duration,  in  order  to  diminish  the  further 
burden  on  the  already  overburdened  eliminative  organs.  In  some  cases  the 
drainage  operation  can  be  carried  out  largely  or  wholly  under  local  anes- 
thesia, aided  by  a  dose  of  morphine  given  about  a  half  an  hour  before.  As 
a  rule  tube-drainage  in  some  form  should  be  employed,  with  or  without 
gauze,  as  preferred.  If  the  pelvic  peritoneal  cul-de-sac  is  to  be  drained 
through  an  abdominal  incision,  the  glass  tube  is  best.  In  other  situations 
rubber  tubing  is  preferable.  It  may  be  split  spirally  or  longitudinally, 
or  may  have  holes  cut  in  the  sides.  If  the  drainage  is  made  per  vaginam,  the 
drainage  tube  should  have  a  cross-piece  (Fig.  637)  to  prevent  it  slipping  out, 
for  in  this  situation  the  tube  must  remain  a  long  time,  as  previously  explained. 


722  ACUTE  PELVIC  INFLAMMATION 

In  cases  where  there  are  several  pockets  which  can  not  be  drained  satisfac- 
torily through  one  tube,  it  may  be  necessary  to  put  in  two  or  more  tubes, 
bringing  them  out  through  the  same  opening  in  the  abdominal  wall  or  through 
separate  openings. 

c.  The  Fowler  Posture.  Immediately  following  the  drainage  operation  the 
head  of  the  bed  should  be  raised  two  feet  (Fig.  738).  This  causes  all  fluid  in 
the  peritoneal  cavity  to  gravitate  to  the  pelvis,  where  it  escapes  through  the 
drainage  tube.  As  soon  as  the  patient  is  strong  enough — that  is,  within  a  day 
or  two — this  drainage  may  be  more  comfortably  and  efficiently  maintained  by 
the  regular  Fowler  posture — half  sitting  posture  (Fig.  739). 

d.  Proctoclysis.  The  introduction  of  normal  saline  solution  into  the  system 
gives  important  aid  to  the  heart  and  kidneys,  and  facilitates  the  elimination 
of  septic  material.  If  the  patient  is  very  weak  immediately  after  the  drainage 
operation,  one  or  two  pints  of  the  solution  may  be  given  subcutaneously.  At 
the  same  time  the  giving  of  the  solution  by  the  rectum  should  be  begun  and 
continued  for  several  days.  It  is  best  given  by  slow  continuous  absorption. 
To  secure  this  certain  essentials  must  be  observed,  as  follows:  (a)  the  fluid 
must  be  maintained  at  a  temperature  of  about  100°  F.,  (b)  it  must  flow  into 
the  rectum  slowly,  drop  by  drop  (about  one  and  a  half  pints  per  hour),  and 
(c)  there  must  be  no  obstruction  or  constriction  in  the  tube  that  would  inter- 
fere with  the  free  regurgitation  of  fluid  or  gas  from  the  rectum.  The  appa- 
ratus, whether  simple  or  elaborate,  must  conform  to  these  essentials.  The  suc- 
cess of  the  method  depends  upon  accuracy  in  its  application.  The  following 
description  is  that  given  by  J.  B.  Murphy,  who  developed  the  method  to  its 
present  perfection : 

"As  soon  as  the  patient  is  returned  to  bed  after  operation,  proctoclysis  is 
instituted  and  maintained  until  the  serious  symptoms  of  intoxication  cease. 
The  continuous  method  is  by  far  the  most  scientific  and  successful.  Moderate 
distention  is  the  normal  condition  of  the  large  intestine.  If  it  is  hyperdis- 
tended,  it  causes  spasm  and  expulsion  of  material.  The  mucosa  of  the  large 
intestine  absorbs  water  with  great  rapidity.  The  retention  of  fluid  in  the 
colon  depends  entirely  upon  the  method  of  its  administration.  "We  have 
visited  hospitals  numbers  of  times  and  have  been  shown  patients  who  were 
receiving  the  "Murphy  treatment."  We  should  not  have  recognized  it  with- 
out the  label.  It  is  difficult  to  impress  those  administering  it  with  the  im- 
portance of  details,  notwithstanding  that  the  best  results  are  secured  only 
by  close  attention  to  detail.  A  fountain  syringe,  to  which  is  attached  a  three- 
eighths-inch  rubber  hose,  fitted  with  a  hard  rubber  or  glass  vaginal  douche  tip 
with  multiple  openings,  was  the  medium  originally  used.  The  tube  should 
be  flexed  almost  to  a  right  angle  tliree  inches  from  its  tip.  A  straight  tube 
must  not  be  used,  as  the  tip  produces  pressure  on  tlie  posterior  wall  of  the 
rectum  when  the  palient  is  in  the  Fowler  position.  Tlie  tube  is  inserted  into 
the  rectum  to  the  flexion  angle  and  secured  in  place  l)y  adliesive  sti-ips,  binding 
it  to  the  side  of  tlie  thigli  so  iliat  it  can  not  come  out  ;  the  ru1)ber  tubing  is 
passed  under  the  sheet  to  the  head  or  foot  of  tlic  1)('(1,  to  Avhich  the  foun- 


TREATMENT  OF  ACUTE  SPREADINGlPERITONITIS 


723 


tain  is  attached.  It  sliouUl  he  suspeiidcd  tVoiii  six  to  ruurteen  inches  above 
the  level  of  the  l)ult()cks  and  raised  or  lowered  to  just  overbalance  hydrostat- 
ically  tlie  intra-nbdoiniiuil  pressui-e — i.  e.,  it  must  be  just  liiwli  enouy-li  lo  rcciuirc 


Fig.  644.  Proctocly.sis  Apparatus  in  Use  in  Murphy's  Clinic.  A,  rectal  tip;  B,  tube  thermometer;  C, 
junction  of  rectal  tube  with  saline  tank  and  with  tube  for  escape  of  gases  and  o^•e^flow;  D,  cup  where  gases 
escape  and  overflow  runs  back  into  saline  tank;  E,  drop-bulb,  where  rate  of  flow  can  be  watched;  F,  clamp  for 
regulating  flow  (a  clamp  is  permi.s.sible  in  this  situation,  but  is  not  permi.«.sil)le  on  the  rectal  tube  proper);  G, 
tube  from  overflow  cup  to  saline  tank;  H,  tube  from  rectal  tube  to  saline  tank;  J,  leg  of  stand;  L,  tank  (inverted 
vacuum  bottle)  for  saline  solution. 


724 


ACUTE  PELVIC  INFLAMMATION 


from  forty  to  sixty  minutes  for  one  and  one-half  pints  to  flow  in,  the  usual 
quantity  given  every  two  hours.  The  flow  must  be  controlled  by  gravity 
alone  and  never  by  a  forceps  or  constriction  on  the  tube,  so  that  when  the 


Fig.  645  A  Simpler  Proctoclysis  Appafatus,  that  may  be  quickly  improvised  (R.  M.  Harbin).  It  consists 
of  a  vacuum  bottle  for  retaining  heat  (this  can  be  found  in  nearly  every  drug  store),  with  a  lilling  funnel  (F), 
which  e.xtends  above  the  fluid  when  the  l)ottle  is  turned  upside  down,  and  an  outlet  tube  leading  to  the  rectal 
tube.  A  tube  thermometer  in  this  outlet  indicates  acc\irately  the  temperature  of  the  solution  passing  to  the 
rectum.  The  free  escape  of  gases  and  of  fluid  from  back-pressure  when  straining  is  provided  for  by  the  tube 
extending  upward.     The  bottle  is  suspended  by  a  scale  (S),  which  shows  the  amount  of  ilnid  d.iscluirged. 


patient  endeavors  to  void  flatus  or  strain  tlie  fluid  can  rapidly  flow  back  into 
the  can,  otherwise  it  will  be  discharged  in  the  bed.  It  is  this  ease  of  flow 
to  and  from  the  })Owel  that  insures  against  overdistention  and  expulsion 
onto  the  linen. 


TREATMENT  OF  ACUTE  SPREADING  PERITONITIS  725 

"The  foimtain  had  better  be  a  glass  or  graded  can,  so  that  the  flow  can  be 
estimated.  The  temperature  of  the  -water  in  the  fountain  can  l)e  maintained 
at  100'^  by  casement  in  liot-water  ])ags.  Tlie  fountain  is  refilled  every  two 
hours  with  one  and  one-half  or  two  pints  of  solution.  The  tube  should  not 
be  removed  from  the  rectum  for  two  or  three  days,  except  for  bowel  movement, 
When  the  nurse  complains  that  the  solution  is  not  being  retained,  it  is  certain 
it  is  not  being  properly  given ;  even  children  tolerate  proctoclysis  surprisingly 
well.  We  have  administered  as  much  as  thirty  pints  of  salt  solution  in  twenty- 
four  hours  and  it  was  all  retained.  We  believe  that,  next  to  the  conserva- 
tive technique  of  the  operative  procedure,  proctoclysis  is  second  in  importance 
as  a  life-saver.  It  rapidly  restores  blood  pressure,  it  improves  the  capillary 
circulation,  it  quiets  the  thirst,  it  eliminates  the  septic  products  and  increases 
the  excretions.  All  of  the  details  are  simple,  but  they  must  be  carried  out 
with  precision  to  secure  the  best  results." 

It  is  not  necessary  to  have  an  elaborate  apparatus.  Dr.  I\Iurphy  accom- 
plished a  large  part  of  his  splendid  results  by  a  simple  fountain  syringe 
properly  arranged.  The  treatment  can  be  more  conveniently  and  accurately 
carried  out,  however,  with  an  apparatus  especially  adapted  to  the  work.  The 
kind  used  in  Dr.  Murphy's  clinic  at  present  is  shown  in  Fig.  644.  It  is  fairly 
simple,  and  yet  accomplishes  all  that  is  necessary  and  in  a  convenient  way. 
A  still  more  simple  form  of  apparatus  and  one  that  can  be  easily  improvised 
is  shown  in  Fig.  645. 

e.  Nourishment  Per  Rectum.  Give  an  ounce  of  some  one  of  the  reliable 
predigested  foods  to  three  ounces  of  normal  saline  solution  every  four  hours. 
This  may  be  given  by  the  drop  method  instead  of  like  amount  of  plain  normal 
saline  solution,  or  it  may  be  given  as  an  ordinary  low  enema  if  it  is  desired 
to  remove  the  tube  for  a  time.  No  large  enemas  are  to  be  used  during  the 
acute  stage,  as  they  might  excite  intestinal  peristalsis.  After  the  process  is 
well  localized  and  the  threatening  symptoms  have  disappeared,  stomach 
feeding  may  be  gradually  resumed. 

f.  Vaccine  Therapy — Serum.  There  are  various  measures  that  tend  to  in- 
crease the  patient's  resistance,  and  these  aid  in  checking  the  progress  of  the 
infection.  In  most  cases  the  treatment  already  mentioned  will  suffice  to 
efifect  a  cure.  In  exceptional  cases,  however,  the  infection  still  continues 
to  spread  and  threaten  the  patient's  life.  This  is  seen  not  infrequently  in 
certain  puerperal  infections — puerperal  peritonitis,  puerperal  cellulitis  and, 
particularly  in  puerperal  septic  thrombo-phlebitis.  All  surgical  indications 
having  been  promptly  met,  we  are  not  yet  through,  but  must  use  every 
possible  means  to  increase  the  patient's  vital  resistance.  There  is  now  a 
severe  conflict  and  in  some  cases  a  prolonged  conflict  between  the  invading 
bacteria  and  the  defending  forces  of  the  body.  Measures  that  increase, 
leucocytosis,  and  strengthen  the  other  resisting  forces,  aid  nature  in  the  fight 
and  may  decide  the  issue  favorably.  Antistreptococcic  serum  has  seemed  to 
aid  materially  in  some  cases.  In  spite  of  the  fact  that  in  many  cases  it  haa 
no  efl'ect  and  that  a  number  of  physicians  have  lost  faith  in  it,  I  am  not  ready 


726  ACUTE  PELVIC  INFLAMMATION 

to  give  it  up.  When  having  a  considerable  experience  in  such  cases,  we  are 
necessarily  guided  by  our  own  observations  and  opinions  to  a  large  extent. 
1  have  used  the  antistreptococcic  serum  many  times  with  no  effect,  but,  on 
the  other  hand,  I  have  repeatedly  noted  marked  improvement  apparently 
due  to  it — that  is,  due  to  nothing  else  so  far  as  I  could  see.  These  are  desperate 
cases,  that  have  gotten  beyond  the  reach  of  direct  measures,  and  the  control 
of  the  situation  has  slipped  out  of  our  grasp.  This  is  not  an  occasion  for  theorr 
izing.  Anything  that  offers  a  substantial  chance  of  improvement  and  will 
do  no  harm  should  be  used.  Consequently,  until  this  subject  is  more  definitely 
cleared  up,  I  shall  continue  to  use  antistreptococcic  serum.  I  use  the  polyv- 
alent serum  in  doses  of  20  c.c,  one  dose  every  24  hours,  until  three  doses 
are  given.  If  no  effect,  no  more  is  used.  If  a  favorable  effect,  the  adminis- 
tration of  serum  is  continued  at  intervals  as  indicated  by  the  temperature. 

Vaccine  therapy,  as  far  as  developed,  has  been  effective  principally  in 
chronic  infections.  A  fcAV  apparently  favorable  results  have  been  reported 
in  the  acute  infections  under  consideration,  but  these  are  uncertain,  and  its 
use  here  is  wholly  experimental  as  yet.  In  an  infection  resisting  other 
measures  it  is  well  to  try  this.  Autogenous  vaccine  is  the  preferable  form, 
but,  if  this  can  not  be  made,  then  use  stock  vaccine — streptococcic,  staphylo- 
coccic or  gonococcic,  as  indicated  by  the  clinical  and  bacteriological  evidences 
in  the  case. 

Employ  also  the  various  other  measures  used  to  increase  or  conserve  the 
patient's  vital  resistance — namely,  concentrated  nourishment,  stimulants,  lax- 
atives, sedatives,  etc.,  according  to  usual  indications. 

6.  Septic  Thrombo-phlebitis.  The  nature  and  ramifications  of  this  process 
have  been  indicated  on  pages  700,  701,  and  as  long  as  the  septic  process  is 
confined  to  accessible  veins  there  is  still  a  chance  to  limit  it  artificially  by 
ligation  of  the  affected  veins  proximal  to  the  infection.  This  subject  is 
still  in  the  experimental  stage.  A  number  of  patients  have  been  operated 
on.  Some  good  has  been  accomplished,  and  there  is  promise  of  more  for  the 
future.  Whenever  a  puerperal  septic  patient  has  repeated  chills  and  high 
fever,  persisting  after  the  uterus  has  been  cleared  out,  and  with  no  general 
lesion  nor  palpable  local  lesion  to  account  for  these  manifestations,  the 
question  of  septic  thrombosis  and  possible  operation  should  be  considered. 
In  these  cases  it  is  important  also  to  employ  the  measures  mentioned  above 
for  increasing  the  patient's  resisting  power. 

7.  In  a  case  of  apparent  pelvic  inflammation  where  the  diagnosis  is 
doubtful,  operation  may  be  indicated  on  account  of  the  probal)ility  or  possi- 
bility of  some  other"  condition,  which  would  require  operation  at  once — such, 
for  example,  as  tubal  pregnancy  or  appendicitis  or  a  suppurating  tumor. 
As  a'  rule,  in  any  of  these  conditions,  if  the  symptoms  are  severe,  immediate 
operation  is  necessary.  Consequently,  in  doubtful  cases,  where  these  con- 
ditions can  not  be  excluded,  if  the  patient  is  growing  worse,  operation  at 
once  is  indicated. 


PROGNOSIS   IN   ACUTE   PELVIC  INFLAMMATION  727 


PROGNOSIS. 


"What  ultiniato  results  can  l)o  oxpocted  in  these  cases  of  acute  pelvic 
inflammation?     What  is  the  ai'ter-histoiy  of  these  patients? 

For  tlie  purpose  of  prognosis  it  is  convenient  to  divide  the  cases  into  two 
classes — (A)  those  not  requiring  operation  and  (B)  those  that  do  require 
operation. 

A.  If  tlie  i)atient  can  be  tided  over  the  most  acute  stage  of  the  attack 
without  operation,   one  of  the  following  terminations  will  take  place. 

1.  Complete  Recovery.  In  these  cases  the  germs  are  destroyed,  the  plastic 
and  serous  exudate  is  absorbed,  the  pains  disappear,  the  patient  comes  to 
feel  well  and  functional  activity  is  restored.  That  such  a  termination  does 
take  place  even  in  some  severe  cases  is  proven  conclusively  by  the  cases 
of  salpingitis  and  pelvic  peritonitis,  from  infection  following  labor  of  abor- 
tion, in  which  the  patients  eventually  recover  and  have  good  health  and 
bear  children.  No  doubt  a  few  adhesions  remain,  Init  not  enough  to  cause 
pain  nor  to  interfere  with  function.  This  very  desirable  termination  is 
much  more  liable  to  take  place  in  ordinary  septic  inflammation  than  in  gon-: 
orrhoeal  inflammation.  In  gonorrhoea!  inflammation  the  immediate  danger 
to  life  is  not  so  marked  as  in  other  forms  of  pelvic  infection,  but  the  ultimate 
danger  to  health  in  the  cases  that  survive  is  much  more  marked.  In  a  much 
larger  proportion  of  the  gonorrhoea!  cases  the  acute  trouble  is  followed  by 
serious  chronic  pelvic  inflammation,  causing  sterility  and  persistent  invalid- 
ism. 

2.  Partial  Recovery.  Functional  activity  is  not  restored.  The  exudate  is 
largely  absorbed  and  the  pains  disappear,  and  the  patient  feels  well.  But 
she  is  sterile — the  sterility  being  due  usually  to  remaining  infiltration  and 
adhesions  that  occlude  the  tubes  and  otherwise  damage  them. 

3.  Chronic  Pelvic  Inflammation.  A  large  percentage  of  the  cases  of 
acute  pelvic  inflammation  terminate  in  chronic  pelvic  inflammation.  There 
may  be  found  a  pelvic  abscess,  w^hich  reciuires  opening  and  drainage  by  way 
of  the  vagina  or  removal  by  abdominal  section.  Llore  frequently,  however, 
there  is  a  mass  of  exudate  without  a  distinct  collection  of  pus,  but  with  a 
focus  of  chronic  inflammation  which  acts  as  a  source  of  constant  irritation, 
causing  pain  on  exertion  and  marked  menstrual  disturbance,  and  giving 
rise  to  frequent  attacks  of  pelvic  peritonitis. 

4.  Death  from  Persistent  Sepsis.  The  patient  survives  the  acute  symp- 
toms at  the  beginning  of  the  attack,  but  still  there  continues  septic  absorption 
or  there  develops  general  pyaemia.  There  is  irregular  fever,  with  repeated 
chills  if  pyaemia  is  present,  emaciation,  increasing  weakness  and  finally 
death,  two  weeks  to  two  months  from  the  outset  of  the  trouble. 

This  result  is  much  more  liable  to  take  place  where  there  is  serious  disease 
elsewhere — for  example,  in  the  kidneys  or  heart,  or  lungs  or  gastro-intestinal 
tract. 


728  CHRONIC  PELVIC  INFLAMMATION 

b.  If  the  inflammation  is  so  severe  that  the  patient's  life  is  threatened 
and  immediate  operation  is  required  and  carried  out,  the  following  are  the 
terminations : 

1.  Complete  Recovery.  Of  the  operative  cases  that  survive  the  acute 
attack  a  large  proportion  are  permanently  cured.  The  patient's  health 
may  be  fully  restored  and  she  is  again  capable  of  child-bearing. 

2.  Partial  Recovery.  The  exudate  is  absorbed,  the  pains  disappear  and 
the  patient  has  good  health — but  she  remains  sterile. 

3.  Chronic  Pelvic  Inflammation.  In  the  septic  cases  following  labor  or 
miscarriage  the  troublesome  post-operative  lesions  are  usually  adhesions 
and  plastic  exudate.  In  the  gonorrhoeal  cases  the  other  tube  is  very  liable 
to  become  inflamed  and  pass  through  the  same  process  as  the  one  removed. 
In  vaginal  drainage  cases,  w^hether  septic  or  gonorrhoeal,  the  drainage  tract 
may  close  too  soon,  allowing  the  abscess  to  reform,  or  another  focus  may  go 
on  to  abscess  formation. 

4.  Death  in  Spite  of  Operation.  In  many  of  these  cases  the  inflammation 
is  so  virulent  that  no  operation  will  stop  its  progress.  On  the  other  hand, 
in  some  of  the  most  threatening  cases  the  patient's  life  is  apparently  saved 
by  operation. 

The  prognosis  in  regard  to  pregnancy  in  patients  who  apparently  recover 
from  acute  pelvic  inflammation,  with  or  without  operation,  is  as  follows : 

1.  If  the  previous  inflammation  was  of  the  ordinary  septic  variety,  there 
is  a  fairly  good  chance  of  pregnancy  later.  Of  course,  such  a  patient  is  not 
so  liable  to  become  pregnant  as  a  perfectly  healthy  woman,  and  if  she  does 
become  pregnant  she  is  more  liable  to  miscarry.  However,  many  women 
who  have  passed  through  one  or  more  attacks  of  severe  puerperal  sepsis,  with 
involvement  of  tubes  and  peritoneum,  recover  apparently  completely  and 
continue  to  bear  children  as  though  there  has  been  no  trouble. 

2.  If  the  previous  inflammation  was  gonorrhoeal,  involving  the  tubes  and 
peritoneum,  there  is  almost  certain  to  be  sterility.  This  is  one  of  the  causes 
of  sterility  in  prostitutes,  and  it  is  also  a  cause  of  many  childless  homes. 
The  husband,  having  previously  had  gonorrhoea  and  supposing  himself  well, 
married  and  unknowingly  carried  infection  to  his  Avife  and  thus  destroyed 
her  chance  of  becoming  a  mother.  Fortunately,  sterility  does  not  invariably 
follow  gonorrhoeal  salpingitis,  some  patients  recovering  sufficiently  to  be- 
come pregnant, 

CHRONIC  PELVIC  INFLAMMATION. 

The  inflammatory  process  may  be  situated  principally  in  the  Fallopian 
tubes  and  pelvic  peritoneum,  or  in  the  pelvic  connective  tissue,  or  in  the 
ovaries. 

ETIOLOGY,   PATHOLOGY,   SYMPTOMATOLOGY. 

In  chronic  pelvic  inflammation  the  separate  forms  of  the  disease  are 
more  distinct  than  in  the  acute  variety— that  is,  the  cases  may  be  divided 


CHRONIC    SALPINGITIS  729 

into  distinct  groups,  representing  the  different  localizations  of  the  inflam- 
matory process  and  differing  considerably  in  etiology,  pathology  and 
symptomatology.  Tlie  cases  may  ])e  divided  into  three  groups — (A)  chronic 
salpingitis  (witli  complicating  oophoritis  and  chronie  pelvic  peritonitis,  caus- 
ing peritoneal  exudate  and  adhesions),  (B)  clironic  pelvic  cellulitis  (para- 
metritis), and  (C)  chronic  oophoritis  (cystic  ovary). 

(A.)   CHRONIC  SALPINGITIS. 

Etiology. 

Chronic  salpingitis  follows  acute  salpingitis.  In  practically  every  case  of 
genital  origin  there  has  been  endometritis  due  to  infection  following  labor, 
or  miscarriage,  or  gonorrhoea.  Chronic  pyosalpinx  alone  (without  involve- 
ment of  the  parametrium)  is  nearly  always  due  to  the  gonococcus,  recog- 
nized or  unrecognized — even  in  the  cases  in  which  the  infection  dates  from 
a  labor  or  miscarriage.  The  detailed  proofs  of  this  fact  and  the  apparent 
exceptions  I  prefer  to  discuss  later,  along  with  its  bearing  on  the  operative 
treatment  of  chronic  inflammatory  masses  in  the  pelvis  (see  pages  748  to  750). 
From  the  endometrium  the  inflammation  extends  to  the  tube,  causing  first 
acute  salpingitis  and  later  chronic  salpingitis. 

Pathology. 

In  chronic  inflammation  of  the  tube  there  are  found  much  the  same  variety 
of  pathological  changes  as  have  been  mentioned  under  acute  inflammation. 
However,  the  serous  exudate  (whether  in  the  cavity  or  in  the  tissues  of  the 
tube  wall)  has  been  largely  absorbed,  and  all  active  infection  is  confined  to 
one  or  more  areas  which  are  well  surrounded  by  plastic  exudate.  Any  collec- 
tion of  pus  is  well  walled  in,  and  in  some  cases  is  sterile  from  long  standing. 
The  adhesions,  which  at  first  vv'ere  simply  fibrinous  exudate,  are  now  organized 
and  contain  fibrous  tissue  and  small  vessels.  Some  of  the  adhesions  now  be- 
come stretched  into  long  bands  or  attenuated  cords,  owing  to  the  constant 
movement  of  the  organs.   The  cases  may  be  divided  in  classes  as  follows : 

1.  Mild  Salpingitis  (Fig.  646).  In  the  cases  of  this  class  the  ends  of  the 
affected  tube  are  occluded  and  the  fimbriae  matted  together  and  distorted, 
and  frequently  adherent  to  the  ovary  or  some  other  adjacent  organ.  The 
wall  of  the  tube  is  thickened  and  the  cavity  is  empty. 

2.  Salpingitis  with  Exudate  (Fig.  647).  In  the  cases  of  this  class  there 
is  a  mass  of  exudate  about  the  tube,  binding  together  the  adjacent  organs, 
but  there  is  no  distinct  collection  of  pus. 

3.  Pyosalpinx  (Fig.  648).  The  occluded  tube  contains  pus.  There  may 
or  may  not  be  extensive  exudate  and  adhesions.  There  is  no  pus  outside 
the  tube. 

4.  Diffuse  Pelvic  Suppuration  (Fig.  649).  In  the  cases  of  this  class  the 
pus  has  extended  outside  the  tube.     As  the  pus  extends  in  various  directions. 


730  CHRONIC  PELVIC  INFLAMMATION 

the  exudate  extends  in  front  of  it,  shutting  it  off  from  the  general  peritoneal 
cavity.  As  in  acute  inflammation,  this  process  may  extend  until  all  the. 
pelvic  organs  are  bound  together  in  an  irregular  mass,  with  pus  lying  in 
the  spaces  between  them. 


Fig.  646.  Mild  Salpingitis  on  the  Left  Side.  Contrast  this  willi  the  normal  right  tube.  Notice  tlie  en- 
largement and  tortuosity  of  the  affected  tube,  and  also  the  distortion  of  the  fimbriae. 

5.  Ovarian  Abscess  (Fig.  650).  The  inflammation  may  extend  to  the 
ovary,  forming  an  ovarian  abscess  in  communication  Avith  a  tubal  abscess 
(Fig.  650,  right  side.)  i\[ore  rarely  there  is  a  distinct  ovarian  abscess  with- 
out  evident  pus  formation  in  the  tube    (Fig.    650/ left   side). 

6.  Hydrosalpinx  (Fig.  651).  The  tube  may  be  much  distended  and  con- 
tains serous  fluid;  but  no  pus.    There  may  or  may  not  be  many  adhesions. 

♦  ■ 


PATHOLOGY  IN  CHKONIC  SALPINGITIS 


731 


7.  Nodular  Salpingitis  (Fig.  652).  The  wall  of  the  tube  becomes  greatly 
thickened,  llie  Ihickeiiing  being  so  irregular  as  to  give  the  tube  a  distinctly- 
nodular  appearance.  Usually  both  tubes  are  affected,  and  fi-cquently  there 
is  also  chronic  oophoritis  of  one  or  both  sides. 

8.  Adhesions   (Fig.  653).     There  is  a  class  of  cases  of  dironic  salpingitis 


Fig.  647,  Salpingitis  with  Exudate.  On  left  side  is  indicated  salpindtis  with  a  few  adhesions.  On 
right  side  is  indicated  salpingitis  with  extensi\e  exudate  and  adhesions.  The  section  indicates  the  relation  of 
the  thickened  tube,  the  ovary,  and  the  surrounding  exudate. 

in  -whieh  the  tubal  troulde  is  slight  or  has  largely  disappeared,  but  the  re- 
sulting peritoneal  adhesions  are  extensive  and  troublesome,  dislocating  the 
tubes  and  ovaries  and  holding  them  firmly  in  abnormal  positions.  In  such 
cases  all  active  infection  may  have  disappeared,  leaving  only  the  sequelae, 
consisting  of  exudate,  adhesions  and  distortions. 


732 


CHRONIC  PELVIC  INFLAMMATION 


Symptoms. 

The  symptoms  of  which  the  patient  complains  in  chronic  pelvic  inflammation 
are  backache  and  pain  in  the  pelvis,  increased  by  walking  or  working.  There 
is  tenderness  in  the  lower  abdomen,  usually  over  one  or  both  tubes.     There 


Fig.  648.  Pyosalpinx.  Left  tube  distended  with  pus,  but  with  a  few  adliesions  Right  tube  distended, 
with  pus  and  surrounded  by  e.xtensive  adhesions.  The  section  on  the  right  side  indicates  the  relation  of  the 
distended  tube  to  the  surrounding  structures.  The  .sectioned  ovary  is  inchoated  dimly  below  and  to  the  outer 
side  of  the  enlarged  tube,  which  has  fallen  behind  and  to  the  inner  .side  of  it. 

are  decided  menstrual  disturbances,  consisting  of  painful  menstruation,  pro- 
longed menstruation  and  an  increase  of  all  the  troublesome  symptoms  at  the 
menstrual  periods.  The  patient  complains  of  weakness  and  loss  of  weight, 
and  an  inability  to  stand  walking  or  working  as  she  formerly  did.  Vaginal 
discharge  is  usually  present,  due  to  the  accompanying  endometritis.     There 


SYMPTOMS  IN  CHRONIC  SALPINGITIS 


733 


occur  also  exacerbations,  in  whicli  the  patieut  lias  sharp  pain  and  some  fever, 
and  is  sick  in  bed  from  a  few  days  to  several  weeks. 

On  examination  there  is  found  tenderness  in  the  tubal  region  of  one  or 
both  sides  and  in  most  eases  a  mass  in  the  same  region.  If  the  inflammation 
is  slight,  there  may  be  no  mass  of  exudate,  but  simply  a  thickening  of  the 
affected  tube.  If  the  inflammation  is  more  marked,  there  is  a  distinct  mass 
beside  the  uterus  in  the  tubal  region,  fixing  the  uterus  to  the  pelvic  wall. 


Fig.  649.  Diffuse  Pelvic  Suppuration  from  Pyosalpinx.  The  pus  lias  broken  through  the  tube  wall,  spread 
among  the  intestinal  coils  and  gravitated  to  the  cul-de-sac.  .\  window,  cut  in  the  distended  tube,  shows  the 
connection  of  the  suppurating  tract  with  the  tubal  ca\'it  J^ 


If  the  inflammation  is  still  more  marked,  the  posterior  cul-de-sac  contains 
a  mass  of  exudate,  or  the  whole  pelvis  may  be  filled  with  a  mass,  which 
forms  a  wall  above  the  plane  of  the  vagina  (Figs.  401,  402),  and  the  uterus 
is  fixed  immovably  in  this  roof  of  exudate.  The  exudate  is  tender  when 
pressed  upon  and,  if  there  is  a  large  collection  of  pus,  fluctuation  may  be 
felt  in  the  cul-de-sac  of  Douglas  or  in  the  tubal  region  of  one  side.  The 
uterus  is  fixed,  and  attempts  to  move  it  cause  pain.     The  amount  of  fixation 


734 


CHRONIC  PELVIC  INFLAMMATION 


or  limitation  of  movement  depends,  of  course,  on  the  extent  of  the  exudate 
and  adhesions. 

The  cases  of  chronic  salpingitis  frequently  present  also  complications — 
laceration  of  pelvic  floor,  laceration  of  cervix,  retroversion  of  uterus  and 
chronic  endometritis.  These  conditions  should  be  searched  for  and  noted, 
for  they  must  be  taken  into  consideration  in  the  treatment. 


Fig.  650.  Ovarian  Ab.scess.  .\  window,  cut  in  tlie  wall  of  the  absces.s  on  the  right  side,  shows  that  it  is 
composed  of  a  tubal  portion  and  an  o\ariai\  portion  (tubo-ovarian  abscess),  with  a  communication  between 
the  two  ca\ities.  On  the  left  side  is  indicated  an  abscess  iuvohing  the  ovary  only,  which  is  a  niiuli  rarer  con- 
dition. 


(B.)     CTTRONTC  PELVTCl  CELLUTJTlJ^  (PARA]\11^7ri{lTlS). 

.  This  is  chronic  inflamiHnlion  of  the  connective  tissue  surrounding  the  u1(M'us. 
There  is  usually  more  or  less  secondary  infiltration  of  the  connective  tissue  in 
all  extensive  pelvic  inflammations,  and  sometimes  pus  of  tubal  origin  will 


CHRONIC  PARAMETRITIS 


735 


make  its  way  into  the  eonne('1i\t'  1  issue.  I>u1  most  of  the  cases  of  well-marked 
cellulitis  are  due  to  extension  of  infeetion  directly  from  the  uterus  into  this 
region. 

Etiology. 

Chronic  cellulitis  is  due  to  a  preceding  acute  cellulitis  and  conseciuently 
has  the  same  causative  factors.    It  is  usually  due  to  infeetion  following  labor 


Fig.  651.     Double  Hydrosalpinx.      The  .sectioned  right  tube  indicate.s  clearlj'  the  marked  thinning  of  the 
wall  found  in  these  case.s. 


or  miscarriage,  the  bacteria  passing  directly  through  the  wall  of  the  uterus 
into  the  connective  tissue  or  through  tears  of  the  cervix.  In  other  cases  it 
can  be  traced  to  operation  on  the  cervix,  to  operation  within  the  uterus,  to 
instrumental  examination  of  the  interior  of  the  uterus,  or  to   attempts   at 


736 


CHRONIC  PELVIC  INFLAMMATION 


abortion.     Cellulitis  alone  (without  tubal  involvement)  is  usually  due  to  the 
streptococcus,  staphylococcus  or  colon  bacillus — practically  never  to  the  gon- 


Fig.  652.     Nodular  Salpingitis.     Tliis  form  of  chronic  salpingitis  is  usually  bilateral,  and  is  often  accom- 
panied by  prolapse  of  the  tube  or  o-\ary  on  one  or  both  sides. 


Fig.  G53.  Multiple  Adhesions  from  Chronic  Pelvic  Inflammation.  This  illustration  represents  a  posterior 
view  of  the  pehac  organs,  with  the  intestinal  coils  pushed  upward  and  to  the  sides  to  show  the  numerous  ad- 
besions. 


CHRONIC  PARAMETRITIS 


737 


ococcus.     This  point  is  further  discussed  under  the  subject  of  the  operative 
treatment  of  these  masses. 

Pathology. 

Pelvic  cellulitis,  like  inflammation  of  connective  tissue  elsewhere,  is  essen- 
tially an  acute  or  subacute  lymphangitis,  running  its  course  and  ending  in 
resolution  or  abscess  formation,  or  a  mass  of  unabsorbed  exudate  and  infiltra- 
tion, which  may  or  may  not  conceal  a  focus  of  pus  in  its  interior.  Occasionally 
the  infection  will  progress  through  the  wall  of  the  uterus  as  a  thrombo- 
phlebitis and  later  break  through  the  broad  ligament  veins  into  the  connective 


-n'tfMaifeftr'iigttiltlfeifttiirr'' ' 


Fig.  654.  Pehic  Cellulitis  (Parametritis.)  The  broad  ligament  inflammatory  mass  is  represented  as  sec- 
tioned longitudinally  on  the  right  side  and  transversely  on  the  left  side.  The  former  (right  side  of  pehis)  in- 
dicates how  the  infiltration  extends  down  along  the  cer\'ix  and  vaginal  wall,  and  the  latter  (left  side)  indicates 
how  it  extends  forward  to  the  bladder  and  backward  to  the  peritoneal  cul-de-sac,  causing  a  convexity  toward 
the  ca%1ty  of  the  cul-de-sac. 

tissue.  The  condition  in  any  particular  case  may  vary  from  a  small  area  of 
induration  on  one  side  of  the  cervix  to  extensive  induration,  involving  the  con- 
nective tissue  all  around  the  uterus  and  extending  out  to  the  pehdc  wall  on 
each  side  (Fig.  654).  The  process  may  extend  forAvard  into  the  connective 
tissue  beside  the  bladder,  or  backward  along  the  sacro-uterine  ligaments.  Fig. 
655  shows  various  situations  in  which  the  mass  may  be  found. 

Symptoms. 
The  symptoms  are  much  the  same  as  those  due  to  salpingitis — namely,  back- 
ache, pain  in  the  lower  abdomen,  tenderness  in  pelvis   and  menstrual  dis- 


738 


CHRONIC  PELVIC  INFLAMMATION 


turbances.     The  severe  exacerbations,  so  characteristic  of  salpingitis,  are  not 
present  usually  in  cellulitis,  unless  there  is  complicating  salpingitis. 

On  examination,  induration  of  extreme  hardness  is  felt  very  low  in  the 
pelvis  and  closely  attached  to  the  sides  of  the  cervix — the  portion  of  the 
uterus  in  contact  with  the  connective  tissue  (Fig.  654).  The  marked  indura- 
tion may  extend  out  to  the  pelvic  wall,  and  may  be  so  intimately  attached 
to  the  bone  and  so  hard  as  to  appear  to  be  a  bony  or  cartilaginous  outgrowth 
from  the  wall  of  the  pelvis.  Other  points  in  the  differential  diagnosis  between 
a  parametritic  mass  and  a  tubal  mass  are  given  on  page  753.    In  some  cases 


Fig.  655.  Indicating  the  Various  Situations  in  which  a  Parametritic  Mass  may  be  found.  A,  close  to  the 
side  of  the  cervix;  B,  at  the  middle  of  the  broad  hgament;  C,  at  the  outer  portion  of  the  broad  Hgament;  D, 
in  the  sacro-uterine  ligament  close  to  the  cervix;  E,  in  the  posterior  portion  of  the  sacro-uterine  ligament;  F, 
at  the  side  of  the  bladder;  G,  in  the  anterior  portion  of  the  pelvis. 

in  which  it  is  difficult  to  determine  certainly  whether  the  induration  is  in  the 
connective  tissue  or  about  the  tube,  the  history  of  the  trouble— its  cause  and 
subsequent  course — will  help  in  distinguishing  between  the  two. 

(C.)     CHRONIC  OOPHORITIS. 

Chronic  inflammation  of  the  ovary  may  be  secondary  or  primary.  Second- 
ary inflammation  of  the  ovary  is  due,  as  a  rule,  to  extension  from  a  salpingitis. 
The  inflammation  about  the  outer  end  of  the  tube  involves  the  adjacent  per- 
itoneum and  ovary.  When  this  takes  place  the  following  conditions  in  the 
ovary  may  result : 

1.  One   or   more  points   of  infection,   with   inflammation,   infiltration   and 


CHRONIC  OOPHORITIS 


739 


swelling — the  mflammation  involving  both  the  follicles  and  the  interfollicular 
connective  tissue.  It  may  or  may  not  progress  to  the  stage  of  abscess  forma- 
tion. "When  an  ovarian  abscess  forms,  it  is  usually  in  connection  with  tubal 
suppuration,  hence  it  was  considered  along  with  salpingitis  (page  730)  and 
Fig.  650). 

2.  The  ovary,  instead  of  becoming  infected,  may  simply  become  surrounded 
by  exudate,  which  compresses  it,  damaging  it  and  causing  cellular  infiltration 
of  the  connective  tissue  (both  the  capsule  and  stroma).  In  time  this  round 
cell  infiltration  forms  scar  tissue,  and  as  it  contracts  it  further  interferes 
with  the  Graafian  follicles,  so  that  they  atrophy  or  form  small  cysts.  From  this 
process  the  functionating  part  of  the  ovary  becomes  reduced  in  size,  and  the 
organ  may  come  to  consist  simply  of  a  mass  of  fibrous  tissue  with  small 


Fig.  656.     Cystic  Ovary.     This  affection  is  usually  bilateral,  and  the  chronically  inflamed  and  heavy  ovary 
is  often  prolapsed. 


cysts  scattered  through  it.  This  condition  is  called  cirrhosis,  and  ovaries 
thus  affected  are  designated  as  "cirrhotic  ovaries." 

Primary  inflammation  of  the  ovary  is  due  to  infection  carried  by  the  blood 
or  to  active  hyperaemia  (from  excessive  sexual  excitement  or  suppression 
of  menses),  or  to  interference  with  the  circulation  (from  malposition,  or  from 
chronic  inflammation  of  the  uterus  or  tubes,  or  from  a  tumor  of  the  uterus,  or 
from  other  pelvic  tumor).  In  the  case  of  infection  the  inflammation  runs 
the  same  course  as  in  oophoritis,  secondary  to  salpingitis. 

In  the  case  of  oophoritis  due  to  circulatory  disturbance  without  infection, 
the  process  is  really  not  inflammation,  but  a  nutritive  disturbance  accom- 
panied with  chronic  irritation.  There  is  chronic  congestion  of  the  ovary, 
round-cell  infiltration  and  enlargement,  with  dilatation  of  the  Graafian  fol- 


740  CHRONIC  PELVIC  INFLAMMATION 

licles.  This  produces  a  large,  heavy,  tender  "cystic  ovary"  (Fig.  656).  The 
heavy  ovary  is  very  liable  to  sink  down  back  of  the  uterus,  low  in  the  pelvis, 
a  condition  known  as  "prolapse  of  the  ovary."  Later,  owing  to  the  con- 
traction of  the  newly-formed  connective  tissue,  the  ovary  may  shrink  and 
become  cirrhotic. 

The  normal  changes  in  the  ovary,  incident  to  the  rupture  of  the  Graafian 
follicles  and  subsequent  scar  formation  (see  Chapter  XII),  produce  appear- 
ances which  are  sometimes  mistaken  for  inflammation. 

The  symptoms  of  infective  inflammation  of  the  ovary  are  about  the  same 
as  those  of  salpingitis.  In  the  non-infective  inflammatory  disturbances  above 
referred  to  (hyperplasia  of  ovary,  cystic  ovary,  cirrhotic  ovary,  prolapse  of 
ovary)  '  the  symptoms  are  much  the  same  as  in  a  chronic  salpingitis,  but 
without  the  severe  exacerbations,  confining  the  patient  to  bed  for  one  or 
two  weeks.  The  symptoms  approach  those  of  a  neuralgic  rather  than  an 
inflammatory  character.  The  patient  is  rarely,  if  ever,  confined  to  bed  more 
than  a  few  hours,  except  in  some  cases  at  the  menstrual  periods.  Examination 
shows  no  mass  of  exudate  about  the  tube,  but  one  or  both  ovaries  are  enlarged 
and  very  tender,  and  possibly  prolapsed.  In  a  later  stage  the  enlarged 
ovary  may  shrink  and  become  smaller  than  normal  (cirrhotic  ovary). 

DIFFERENTIAL  DIAGNOSIS  OF  CHRONIC  PELVIC  INFLAMMATION. 

The  diseases  which  may  be  confounded  with  chronic  pelvic  inflammation, 
and  which  therefore  must  be  taken  into  consideration  in  the  differential 
diagnosis,  are  as  follows : 

Chronic  endometritis. 

Fibromyoma  of  the  uterus. 

Tubal  pregnancy,  with  chronic  symptoms. 

Tuberculosis  of  the  tubes  and  peritoneum. 

Syphilis  of  the  pelvic  structures. 

Ovarian  and  broad  ligament  tumors. 

Chronic  appendicitis. 

Mucous  colitis. 

Bladder  and  rectal  affections. 

Pelvic  neuralgia. 

Neurasthenia. 

Hysteria.  , 

In  chronic  endometritis,   without  pelvic  inflammation,  the  trouble  is  con-^ 
fined  to  the  uterus,  and  consequently  there  is  no  marked  tenderness  nor  any 
inflammatory  mass  outside  the  uterus. 

A  fibroid  tumor  of  the  uterus  usually  presents  the  following  points: 

a.  The  symptoms  are  of  gradual  onset,  and  consist  principally  of 
menstrual  disturbances,  particularly  increased  flow. 

b.  Absence  of  fever  and  absence  of  attacks  of  pelvic  peritonitis.    . 

c.  The  mass  is  hard,  has  a  definite  and  rounded  outline,  is  intimately 
connected  with  the  uterus  and  not  attached  to  the  pelvic  wall. 


DIAGNOSIS  OF  CHRONIC  PELVIC  INFLAMMATION  741 

d.  There  is  not  the  marked  tenderness  that  is  found  in  pelvic  inflamma- 
tion. 

e.  There  is  no  fixation  unless  the  tumor  is  large  enough  to  impinge  on 
the  pelvic  wall.  The  uterus  and  tumor  are  movable  together,  but  not  separ- 
ately. 

f.  If  necessary  to  sound  the  uterus,  it  will  usually  be  found  increased 
in  depth. 

Ovarian  and  broad  ligament  tumors  present  the  following  characteristics : 

a.  Gradual  onset  of  symptoms. 

b.  Absence  of  fever  and  of  marked  menstrual  disturbance  and  of  severe 
attacks  of  pelvic  peritonitis. 

c.  Large  tumor  mass  without  particular  tenderness  and  without  fixation. 
In  the  case  of  an  ovarian  tumor  the  mass  can  usually  be  moved  about  in  the 
lower  abdomen. 

d.  Distinct  fluctuation  without  marked  tenderness,  indicating  that  the 
fluid  is  not  pus. 

Tuberculosis  of  tubes  and  peritoneum.  The  distinguishing  characteristics 
of  tuberculosis  of  the  tubes  and  peritoneum  are : 

a.  Decided  symptoms  of  pelvic  inflammation  in  a  young  woman  who  has 
had  no  opportunity  to  contract  pelvic  inflammation — that  is,  in  a  woman 
who  has  never  had  endometritis. 

b.  Gradual  onset,  usually,  and  persistent  progress  without  the  marked 
improvement  usually  following  the  treatment  of  ordinary  pelvic  inflammation. 

c.  Encysted  ascites — a  collection  of  fluid  shut  oil  from  the  general  peritoneal 
cavity  by  adhesions — without  the  marked  pain  and  fever  that  would  come 
with  a  collection  of  pus. 

d.  Evidence  of  tuberculosis  elsewhere. 

c.  Emaciation,  gradual,  but  marked  and  persistent — more  so  than  would 
be  accounted  for  by  the  pain,  fever,  etc. 

Syphilis  of  the  tubes  and  peritoneum  sufficient  to  cause  symptoms  is  rare, 
but  it  should  always  be  borne  in  mind  in  patients  presenting  marked  evidence 
of  syphilis,  especially  if  there  is  severe  ulceration  of  the  genitals  or  rectum 
or  if  there  is  stricture  of  rectum.  All  such  patients  presenting  symptoms  of 
chronic  pelvic  inflammation  should  be  given  a  thorough  course  of  potassium 
iodide  before  operation  is  decided  upon. 

It  is  the  cellular  deposit  of  the  tertiary  stage  that  attacks  these  structures. 
The  symptoms  pointing  to  such  trouble  are: 

a.  Evidence  of  syphilis  elsewhere  in  the  body. 

b.  Gradual  onset  of  the  trouble,  usually  in  connection  with  some  other 
active  evidence  of  syphilis  in  the  third  stage. 

c.  Less  decided  fever  and  tenderness  than  in  ordinary  inflammation. 

d.  No  fluctuation,  but  extensive  adhesions,  which  bind  the  organs  together 
in  such  a  way  as  to  form  distinct  masses,  which  may  be  mistaken  for  masses 
of  plastic  exudate. 

e.  The  recently  developed  reactions  for  syphilis   (Wassermann,  Noguchi) 


742  CHRONIC  PELVIC  INFLAMMATION 

and,  where  a  portion  of  affected  tissue  can  be  excised,  esamination  for  the 
spirochete  pallida. 

Though  this  syphilitic  condition  in  the  pelvis  is  rare,  it  occasionally  occurs 
and  must  be  watched  for  in  syphilitics.  In  more  than  one  such  patient  the 
abdomen  has  been  opened,  only  to  find  the  case  not  a  proper  one  for 
operation — the  abdomen  being  closed  and  the  patient  placed  on  anti-syphilitic 
treatment,  which  should  have  been  given  before  operation. 

Chronic  appendicitis  may  be  difficult  to  differentiate  from  chronic  salpin- 
gitis of  the  right  side.    The  facts  pointing  to  appendicitis  are  as  follows : 

a.  High  location  of  the  painful  area,  at  McBurney's  point,  without  a 
painful  area  at  the  site  of  the  Fallopian  tube. 

b.  Stomach  and  intestinal,  disturbance,  preceding  and  accompanying  an 
attack.    Also  pain  in  region  of  the  umbilicus,  rather  than  in  the  back. 

c.  High  location  of  the  mass  of  exudate — not  felt  so  well  from  vagina  as 
would  be  a  mass  about  the  Fallopian  tube. 

d.  Absence  of  endometritis  and  absence  of  a  history  of  previous  uterine 
sepsis  or  gonorrhoea. 

e.  No  marked  increase  of  the  trouble  at  the  menstrual  periods.  Even 
appendicitis  may  show  some  increase  then,  but  it  is  not  so  marked  as  in 
salpingitis. 

In  a  case  of  inflammation  in  the  right  lower  abdomen  in  a  girl,  or  in  a 
woman  who  has  never  been  pregnant  nor  had  any  uterine  infection,  the 
trouble  is  more  likely  to  be  appendicitis.  On  the  other  hand,  in  a  case  of 
inflammation  in  that  locality  in  a  woman  who  has  once  had  infection  of 
the  uterus,  the  probability  is  in  favor  of  salpingitis.  In  some  cases  it  is 
impossible  to  make  a  positive  differential  diagnosis  until  the  abdomen  is 
opened.  In  fact,  it  not  infrequently  happens  that  both  structures  are  involved 
in  the  inflammatory  process,  the  inflammation  beginning  in  the  tube  and 
extending  to  the  appendix  or  beginning  in  the  appendix  and  extending 
to  the  tube. 

Other  intestinal  diseases  also  must  be  excluded.  Mucous  colitis  is  the  one 
which  has  most  frequently  been  mistaken  for  chronic  tubal  or  ovarian  inflam- 
mation (see  page  300).  .  The  points  that  distinguish  mucous  colitis  from 
chronic  pelvic  inflammation  are  (a)  the  character  of  the  pain  (resembling 
intestinal  cramps  and  extending  throughout  the  lower  abdomen),  (b)  the 
passage  of  characteristic  masses  of  mucus  in  some  of  the  attacks  and  (c) 
the  absence  of  any  palpable  pelvic  lesion. 

There  are  also  diseases  of  the  urinary  organs  that  may  be  confounded  with 
chronic  pelvic  .inflammation.  All  those  affections  must  be  excluded  by  a 
knowledge  of  the  symptoms  and  signs  that  accompany  them. 

In  pelvic  neuralgia  and  in  neurasthenia  and  in  hysteria,  without  complicat- 
ing pelvic  inflammation,  there  is  no  abnormal  mass  within  the  pelvis.  In 
pelvic  neuralgia  the  tenderness  may  be  localized  along  the  pelvic  nerve 
trunks  (Figs.  87,  88). 


TREATMENT  OF  CHRONIC  PELVIC  INFLAMMATION  743 

TREATMENT. 

In  the  treatment  of  chronic  pelvic  inflammation  (chronic  salpingitis,  chronic 
oophoritis,  chronic  pelvic  peritonitis,  chronic  pelvic  cellulitis,  and  all  combi- 
nations of  these  lesions)  there  are  certain  general  measures  that  are  appli- 
cable to  practically  all  cases,  and  there  are  also  special  measures  that  are 
applicable  to  special  conditions  only. 

GENERAL  MEASURES. 

1.  Laxatives  as  needed  to  overcome  chronic  constipation.  Cascara  sagrada 
is  an  excellent  laxative  for  this  purpose  after  the  bowels  have  been  thorough- 
ly moved  by  some  more  active  purgative.  I  have  used  with  much  satisfaction 
the  laxative  pills  containing  aloin,  belladonna,  strychnia  and  cascara  (see 
Formulae),  one  pill  each  night  or  one  each  night  and  morning. 

2.  Attention  to  the  general  health,  as  indicated  by  anemia,  lithemia  or 
other  abnormal  condition.  This  is  particularly  important  in  chronic  pelvic 
diseases  if  satisfactory  results  from  treatment  would  be  secured.  Just 
because  the  patient  has  some  pelvic  disease,  do  not  jump  at  the  conclusion 
that  treatment  of  that  alone  will  cure  her.  There  may  be  an  affection  in 
some  other  part  of  the  body  that  has  far  more  to  do  with  the  patient's  ill 
health.  And  even  considering  the  effect  on  the  pelvic  affection  only,  the 
general  health  should  be  built  up  as  much  as  possible. 

3.  Rest  at  the  menstrual  periods.  If  the  patient  suffers  much,  she  should 
go  to  bed  and  have  hot  applications  made  to  the  lower  abdomen.  If  this  does 
not  give  relief,  she  should  be  given  sedatives  as  necessary,  but  avoid  opium. 

4.  Hot  vaginal  douches,  one  to  three  times  daily.  To  secure  the  best 
result,  these  must  be  given  according  to  the  special  directions  detailed  in 
Chapter  III. 

5.  Applications  to  the  vaginal  vault.  Ichthyol  (10  per  cent.)  in  glycerine, 
and  applied  by  means  of  tampons  every  second  or  third  day,  aids  some  in 
relieving  the  pain  and  hastening  the  absorption  of  the  exudate. 

6.  Applications  to  the  lower  abdomen.  These  consist  principally  in  counter- 
irritation  by  means  of  tincture  of  iodine  applied  over  the  tubo-ovarian  region 
of  one  or  both  sides.  This  is  useful  particularly  in  chronic  or  subacute 
oophoritis  and  in  ovarian  neuralgia.  The  patient  is  given  a  prescription 
for  an  ounce  bottle  of  the  tincture  and  a  camels-hair  brush.  She  is  directed 
to  paint  the  iodine  over  the  painful  region  once  daily  until  the  skin  becomes 
tender,  then  stop  for  a  few  days  until  the  skin  irritation  subsides,  then  use 
the  iodine  again  until  the  skin  becomes  tender,  and  so  on  as  long  as  desired. 
By  this  means  mild  counter-irritation  may  be  kept  up  over  the  painful 
ovary  for  weeks,  with  decided  diminution  of  pain  in  some  cases. 

SPECIAL  MEASURES. 

1.  If  there  is  a  collection  of  pus  low  in  the  pelvis,  open  and  drain  it  by 
vaginal  operation,  according  to  the  technique  given  in  detail  under  acute 


744  CHRONIC  PELVIC  INFLAMMATION 

pelvic  inflammation  (see  page  705).  In  the  after-treatment  the  drainage- 
tube  will  have  to  remain  in  longer  than  for  an  acute  abscess  of  the  same 
size,  for  the  chronic  abscesses  have  thicker  walls  and  hence  collapse  more 
slowly. 

2.  If  there  is  an  inflammatory  mass  high,  which  probably  contains  pus  or 
which  continues  to  give  serious  trouble  after  a  thorough  trial  of  the  general 
measures  (that  is,  after  those  measures  have  been  used  faithfully  for  several 
weeks  along  with  rest  in  bed  as  thought  best),  then  comes  the  question  of 
abdominal  operation.  Intimately  associated  with  this  is  another  important 
question,  namely: 

What  is  the  Preferable  Time  for  Abdominal  Operation  for  a  Chronic 
Inflammatory  Mass  in  the  Pelvis? 

In  a  considerable  proportion  of  the  cases  of  chronic  suppuration  in  the 
pelvis  the  pus  is  sterile  at  the  time  of  operation.  In  634  cases  examined 
bacteriologically  (collected  by  Andrews  and  comprising  series  by  Charrier, 
Hartman  and  Morax,  Kelly,  Koch,  Legros,  Martin,  Menge,  Orthmann,  Proch- 
ownik,  Reichel,  Schafi^er,  Schauta,  Schenk,  Schmitt,  Stemann,  Strassmann, 
"Wertheim,  Westermark,  "Whiteside,  "Witte,  Zweifel,  Rist,  Mackenrodt,  Durck, 
Bellei,  Walsh,  Frommel,  and  Andrews)  the  results,  excluding  tubercular  cases, 
were  as  follows: 

Sterile   55.     per  cent. 

Only  saprophytes 6.     per  cent. 

Gonococcus 22.5 

Streptococcus  and  staphylococcus 12. 

Pneumococcus  2. 

Bacillus  coli  communis 2.5 

In  a  later  resume,  by  Hyde,  comprising  nearly  three  thousand  cases  (2973 
cases,  excluding  tubercular),  the  bacteriologic  findings  were  approximately 
as  follows:  sterile,  1998;  gonococcus,  579;  other  bacteria  and  mixed  infec- 
tions, 456. 

It  is  interesting  to  note  the  steps  in  the  development  of  this  knowledge.  Long 
ago  it  was  observed  that,  of  the  patients  subjected  to  abdominal  operation  for 
pelvic  suppuration,  the  old  cases  usually  recovered  promptly,  while  the  recent 
cases  frequently  developed  fatal  peritonitis — that  is,  operation  in  the  acute 
stage  was  far  more  dangerous  than  operation  in  the  chronic  stage. 

The  splendid  advance  in  gynecologic  work  in  the  last  few  decades  is  based 
on  facts  ascertained  in  two  ways.  Some  facts  came  to  the  surface  largely 
through  pathologic  and  bacteriologic  investigation,  while  others  were  ascer- 
tained by  experience  at  the  operating  table  and  the  bedside.  The  fact  above 
referred  to  belongs  to  the  latter  class ;  it  was  learned  by  experience,  often  bitter 
experience,  and  many  lives  were  lost  before  the  lesson  was  fully  learned. 

This  fact,  after  having  been  clinically  established,  was  the  occasion  of  much 


CLASSIFICATION  OF  INFLAMMATORY  MASS  745 

curiosity,  as  the  explanation  was  not  at  hand.  It  seemed  paradoxical  that 
long  continuance  of  a  debilitating  disease  should  put  the  patient  in  better 
condition  for  a  serious  operation  for  the  same. 

"What  could  be  the  explanation?  Why  did  chronic  inflammation  confer 
such  immunitj^  from  peritonitis  after  operation?  One  early  theory  was  that 
the  immunity  was  due  largely,  if  not  wholly,  to  the  local  effect  on  the  adja- 
cent peritoneum,  choking  its  absorptive  channels  so  that  serious  septic  absorp- 
tion could  not  take  place  so  readily,  and  modifying  the  membrane  so  that 
it  was  not  as  good  culture  ground  for  the  bacteria.  According  to  another 
hypothesis  the  body  resistance  generally  became  "accustomed"  to  the  local 
irritation  in  the  pelvis  and  consequently  was  less  disturbed  by  the  added 
irritation  of  operation,  and  also,  owing  to  the  preparedness,  so  to  speak,  of 
the  general  resistant  forces  of  the  body,  they  were  better  able  to  combat  in- 
vasion. These  explanations  were  but  gropings  in  the  dark,  but  nevertheless 
they  contained  truths  which  have  been  verified  and  elucidated  by  the  epoch- 
making  investigation  into  the  resistant  functions  of  the  leucocytes  and  the 
blood-serum,  and  into  the  modus  operandi  of  antitoxin  and  vaccine  therapy. 

The  decisive  step  in  the  solution  of  the  riddle  was  the  inauguration  of 
systematic  bacteriologic  examination  of  specimens  removed  in  operations 
for  pelvic  suppuration.  These  bacteriologic  examinations  were  undertaken 
primarily  for  the  purpose  of  determining  the  etiology  of  salpingitis,  particu- 
larly what  proportion  of  the  cases  were  due  to  the  gonococcus  and  what 
proportion  to  other  bacteria.  The  results  were  disappointing.  In  a  con- 
siderable proportion  of  the  cases  no  bacteria  could  be  found  and  hence 
in  those  cases  the  etiology  of  the  trouble  could  not  be  bacteriologically 
determined.  But,  though  disappointing  so  far  as  concerned  the  definite  etio- 
logical classification  of  cases,  the  facts  thus  ascertained  were  very  illuminating 
in  regard  to  the  important  and  puzzling  question  as  to  why  immunity  was 
secured  by  waiting.  In  many  cases  the  bacteria  had  died  and  disintegrated 
and  the  pus  was  sterile — that  was  the  reason  why  serious  inflammation 
seldom  followed  abdominal  section  for  old  tubal  abscesses,  even  though  con- 
siderable pus  often  escaped  among  the  pelvic  structures  during  the  enuclea- 
tion. On  the  other  hand,  in  fresh  cases  the  least  peritoneal  contamination 
by  the  contained  pus  was  often  followed  by  fatal  peritonitis  because  the 
bacteria  were  not  dead,  but  active  and  virulent.  Another  fact  ascertained 
was  that  in  many  of  the  old  cases  in  which  bacteria  were  still  present  they 
were  so  attenuated  that  the  pus  was  practically  sterile. 

Persistence  of  Virulence — Classification  of  Cases. 

It  ha^nng  been  established  that  sterilization  gradually  takes  place  within 
a  reasonable  time  in  most  cases,  the  next  problem  is  to  determine  the  period 
of  time  required  for  the  automatic  sterilization  or  effective  attenuation  in 
the  different  classes  of  cases. 

The  persistence  of  virulence  depends  largely  on  the  character  of  the 
infection.    The  two  principal  infectious  agents  in  pelvic  inflammatory  masses 


746  CHRONIC  PELVIC  INFLAMMATION 

are  the  gonoeoceus  and  the  streptococcus.  These  two  differ  widely  in  the 
persistence  of  virulence  and  also  in  certain  clinical  characteristics  which  can 
be  distinguished  before  operation. 

For  the  purpose,  then,  of  considering  the  persistence  of  virulence  in  a  prac- 
tical way — i.  e.,  as  a  guide  to  treatment — the  cases  of  chronic  pelvic  suppura- 
tion (tubercular  excluded)  may  be  divided  into  two  classes — the  gonococcic 
and  the  streptococcic.  To  be  useful,  this  classification  must  be  made  before 
operation — that  is,  it  must  be  a  clinical  rather  than  a  strictly  bacteriological 
classification.  Of  course,  from  a  bacteriologic  standpoint  there  are  other  cases, 
due  to  other  bacteria,  but  in  the  present  state  of  knowledge  these  other  cases 
can  not,  as  a  rule,  be  distinguished  before  operation,  and,  even  if  they  were 
distinguished,  not  enough  information  has  accumulated  to  show  the  average 
persistence  of  virulence  in  such  cases.  Consequently,  when  confronted  with  a 
case  of  non-tubercular  chronic  pelvic  inflammation,  the  endeavor  should  be 
to  decide  whether  it  belongs  to  the  gonococcic  or  streptococcic  class,  ignoring 
for  the  time  the  fact  that  it  may  possibly  be  due  to  other  bacteria,  which  in 
point  of  virulence  lie  between  these  two  extremes. 

How  may  the  gonococcic  and  the  streptococcic  cases  be  distinguished  be- 
fore operation?  What  diagnostic  facts  are  available  at  that  time?  Bacte- 
riologic examination  of  the  urethral  or  uterine  or  other  discharge  is  of  assist- 
ance in  only  a  small  proportion  of  these  chronic  cases,  for  as  a  rule  the  bac- 
teria have  disappeared  from  the  discharge.  Neither  is  there  at  present  any 
well-established  specific  diagnostic  reaction  in  gonoeoceus  or  streptococcus 
cases  corresponding  to  the  tubercular  reaction  in  tubercular  cases.  Hence 
we  must  depend  on  other  information  obtainable  before  operation.  Fortun- 
ately the  gonorrhoeal  cases  and  the  streptococcal  cases  differ  usually  in  two 
particulars — namely,  (a)  in  the  apparent  cause  of  the  trouble  and  (b)  in  the 
location  of  the  lesion.  As  a  rule  these  distinguishing  points  may  be  settled 
and  the  case  definitely  classified  by  an  accurate  inquiry  into  the  onset  of  the 
trouble  and  a  careful  bimanual  examination. 

Uncertain  cases  are  to  be  classed  with  one  or  the  other,  as  the  preponderance 
of  evidence  warrants,  and  are  to  be  given  treatment  accordingly.  After 
operation,  bacteriologic  examination  may  show  other  bacteria,  either  alone 
or  associated,  and,  if  accurate  records  are  kept  of  the  histories  and  bacterio- 
logic findings  in  large  series  of  cases,  it  may  be  possible  later  to  form  a  third 
clinical  class,  comprising  one  or  more  of  the  miscellaneous  or  mixed  infec- 
tions. For  the  present,  however,  the  two  classes,  gonococcic  and  strepto- 
coccic, are  all  that  can,  as  a  rule,  be  satisfactorily  distinguished  before 
operation. 

Gonococcic  Class  (Clinical). 

In  the  gonococcic  class  (clinical)  the  distinguishing  points  are:  (1)  that  the 
pelvic  inflammation  is  preceded  by  evidence  of  gonorrhoea  or  comes  on  with- 
out apparent  cause,  and  (2)  that  the  lesion  is  located  in  the  tube,  extending 
thence  to  the  ovary  or  adjacent  peritoneal  surfaces,  but  not  involving  the  con- 


GONOCOCCIC  INFLAMMATORY  MASSES  747 

nective  tissue  (parametrium)  to  any  decided  extent.  As  so  much  diagnostic 
importance  is  attached  to  these  two  points,  it  is  necessary  to  consider  them 
somewhat  in  detail. 

a.  Apparent  cause  or  mode  of  onset.  As  a  general  proposition  it  may  be 
said  that  the  gonococcus  is  the  only  germ  that  will  spontaneously  invade  the 
normal,  non-puerperal  uterus  and  tubes.  There  are  exceptions.  Reidel  re- 
ported that  of  56  girls  under  ten  years  of  age  operated  on  for  appendicitis, 
five  had  peritonitis  due,  not  to  appendicitis,  but  to  acute  salpingitis.  He 
states  positively  that  the  infections  reached  the  tubes  by  way  of  the  vagina 
and  uterus,  and  that  gonorrhoea  was  excluded  in  every  case.  Cultures  showed 
the  ordinary  pus  germs.  The  inflammation  was  virulent  and  every  patient 
died  in  spite  of  operative  treatment.  He  observed  the  same  clinical  picture  in 
two  girls  past  ten  years  of  age,  both  of  whom  died.  In  contradistinction  to 
these  cases  in  children,  he  states  that  he  has  never  seen  such  penetration  of 
normal  genitalia  by  streptococci  or  staphylococci  in  the  adult. 

General  experience  is  in  accord  with  this  statement  in  regard  to  adults. 
Purulent  inflammation  beginning  in  a  normal  adult  non-puerperal  vagina  or 
uterus,  and  later  extending  out  into  the  pelvic  cavity,  may  be  set  down  as 
almost  certainly  gonorrhoeal.  The  patient  must  of  course  be  questioned 
closely  enough  to  eliminate  an  early  miscarriage  and  also  any  intrauterine 
instrumentation  (curetment,  intrauterine  treatment,  sounding  in  examina- 
tion, etc.)  The  probability  of  gonorrhoea  is  increased  if  the  purulent  dis- 
charge ("free  leucorrhoea")  began  within  a  few  weeks  after  marriage. 
Again,  in  a  large  proportion  of  the  cases  of  gonococcal  leucorrhoea  there  is 
urethritis,  causing  burning  on  urination  and  increased  frequency  of  urina- 
tion. This  discharge  and  disturbance  of  micturition  may  last  a  few  days  or 
much  longer.  It  may  precede  the  pelvic  inflammation  by  a  few  days  or  a 
few  weeks  or  a  few  months.  A  history  of  abscess  of  one  of  the  vulvo-vaginal 
glands  has  about  the  same  significance  as  a  history  of  urethritis.  These  struc- 
tures are  frequently  involved  in  gonococcal  leucorrhoea,  but  very  seldom  in 
leucorrhoea  from  other  causes. 

In  those  cases  where  the  vaginal  and  uterine  gonorrhoea  did  not  cause 
sufficient  disturbance  to  be  noticed,  the  pelvic  inflammation  began  without 
apparent  cause.  A  considerable  proportion  of  the  gonorrhoeal  cases  give  such 
a  history.  Here,  again,  one  must  be  careful  not  to  overlook  an  early  miscar- 
riage or  some  intrauterine  instrumentation.  Also,  it  is  important  to  trace 
the  inflammation  back  to  its  very  beginning,  for  some  cases  of  puerperal  in- 
fection are  very  mild  in  outward  manifestations  and  do  not  cause  much 
trouble  until  there  is  an  exacerbation  after  several  weeks  or  months.  In  these 
cases,  however,  there  is  usually  a  history  of  some  disturbance  during  the 
puerperium,  from  which  the  patient  recovered  to  a  large  extent,  but  not  en- 
tirely. On  the  other  hand,  an  inflammatory  trouble,  at  first  apparently  due  to 
a  miscarriage  or  full  term  delivery,  may  on  careful  ciuestioning  be  found  to 
antedate  the  pregnancy  and  to  be  due  to  a  preceding  gonorrhoeal  infection. 

In  the  examination  a  search  should  be  made  about  the  external  genitals  for 


748  CHRONIC  PELVIC  INFLAMMATION 

evidences  of  an  old  gonorrhoea — signs  of  previous  inflammation  of  the  urethra 
or  of  the  vulvo-vaginal  glands,  such  as  red  spots  (maculae  gonorrhoea)  in 
these  situations,  or  secretion  that  can  be  pressed  from  the  structures.  Bac- 
teriologic  examination  of  discharge  from  the  urethra,  vulvo-vaginal  glands, 
vagina  or  cervix  may  show  gonococci.  Negative  findings,  however,  do  not 
exclude  gonorrhoea,  for  in  many  of  the  chronic  causes  the  causative  bacteria 
have  disappeared  from  the  discharge. 

In  a  certain  proportion  of  cases  of  gonococcic  pelvic  inflammation  the  ex- 
tensions of  the  gonococci  into  the  uterus  and  beyond  took  place  during  the 
puerperium.  It  has  been  shown  that  the  gonococcus  may  lie  practically  dor- 
mant in  the  lower  part  of  the  genital  tract  for  a  long  time  and  extend  up- 
ward after  a  labor  or  miscarriage.  Sanger  examined  389  pregnant  women 
and  found  the  gonococcus  in  100.  Steinbuckel  examined  the  lochia  in  274 
women  in  which  the  puerperium  was  normal  and  found  the  gonococcus  in  18 
per  cent.  In  Leopold's  clinic,  25  per  cent  of  the  puerperal  infections  were  of 
gonorrhoeal  origin.  In  179  cases  of  puerperal  sepsis  examined  bacteriologic- 
ally  by  Kronig,  50  cases  were  gonococcal,  50  belonged  to  the  sapraemic 
group  (miscellaneous  saprophytes,  most  of  which  did  not  grow  in  ordinary 
culture  media)  and  79  were  due  to  the  ordinary  pus  bacteria.  Puerperal  in- 
fection due  to  the  gonococcus  is  nearly  always  of  a  mild  type,  as  shown  in  an 
instructive  article  by  Taussig.  A  history  indicating  that  the  attack  of  puer- 
peral sepsis  was  mild  may  help  some  in  differentiation,  though  it  must  be 
kept  in  mind  that  puerperal  infection  from  other  bacteria  may  also  run  a 
mild  course.  In  the  cases  of  puerperal  origin,  therefore,  without  positive  evi- 
dence of  gonorrhoea,  the  decision  must  rest  largely  on  the  location  of  the 
lesion. 

b.  Location  of  the  lesion.  The  extension  of  gonorrhoeal  inflammation  is 
almost  invariably  along  the  uterine  mucosa  into  the  tube  (Fig.  657),  and  any 
further  extension  is  toward  the  ovary  and  the  peritoneal  cavity.  Gonococci 
very  seldom  extend  through  the  uterine  wall  into  the  parametrium.  Even 
when  they  do  extend  into  the  connective  tissue,  they  are  not  likely  to  form 
an  inflammatory  mass  there.  Steinschneider  and  Schaefer  injected  pure  cul- 
tures of  gonococci  into  connective  tissue,  but  no  decided  inflammatory  action 
resulted.  Though  parametrial  abscess  may  occasionally  result  from  gono- 
cocci, as  demonstrated  by  Wertheim  and  others,  it  is  so  rare  as  to  be  a 
curiosity. 

The  characteristic  lesion,  therefore,  of  gonorrhoea  in  the  pelvis  is  pyosal^ 
pinx,  with  or  without  the  complicating  oophoritis  and  pelvic  peritonitis.  The 
great  majority  of  all  pus-tubes  are  due  to  gonorrhoeal  infection,  known  or 
unknown.  In  106  cases  of  purulent  salpingitis  examined  by  Menge  the  find- 
ings were  as  follows :  sterile  pus  in  68,  gonococci  in  22,  tubercle  bacilli  in  9, 
staphylococcus  in  1,  anaerobic  bacteria  in  2,  and  streptococci  in  4.  As  we 
shall  see  later,  the  gonococcus  often  dies  out  within  a  comparatively'  short 
time,  so  it  is  probable  that  most  of  the  sterile  cases  originate  from  the  gono- 
coccus.  When  this  fact  is  taken  into  consideration  it  becomes  apparent  what 


GONOCOCCIC  INFLAMMATORY  MASSES 


749 


a  large  proportion  of  the  cases  of  purulent  salpingitis  are  due  to  the  gono- 
coeeus  and  what  a  small  proportion  to  other  bacteria. 

In  a  recent  article  on  this  subject*  I  gave  the  details  of  a  series  of  cases  of 
the  gonococcic  class  (clinical),  showing  the  two  principal  diagnostic  points  be- 
fore operation,  the  interval  of  time  from  infection  to  operation,  the  bacteria 
found  at  operation,  and  the  degree  of  virulence  (as  indicated  by  the  result  of 
the  operation). 

The  cases  thus  tabulated  in  detail  may  be  taken  as  typical  of  the  hundreds 
of  cases  of  this  common  class,  which  include  probably  five-sixths  of  the 
chronic  inflammatory  masses  in  the  pelvis.  These  cases  are  so  common  and 
run  such  a  uniform  course  that  but  few  are  reported  in  sufficient  detail  to 


Fig.  657.     Gonococcal  Infection  of  Uterus  and  Resulting  Lesion.     Gonococcal  inflammation  extends  along 
the  mucosa  to  the  tube  (as  indicated  in  left  side),  and  causes  pyosalpinx  (right  side). 


show  definitely  the  apparent  cause,  the  interval  of  time  from  infection  to 
operation,  the  location  of  the  lesion  and  the  bacteriological  findings.  It  would 
be  well  if  several  series  from  the  larger  clinics  were  reported,  so  as  to  show 
the  points  mentioned,  that  the  pre-operative  diagnosis  of  the  character  of  the 
infection  and  the  probable  virulence  may  be  more  clearly  defined. 

It  will  be  noticed  in  the  article  mentioned  that  in  some  of  the  cases  belong- 
ing clinically  to  the  gonococcic  class,  bacteriologic  examination  showed  other 
bacteria  instead  of  the  gonococcus.  But  they  are  placed  in  this  clinical  class 
because  of  the  apparent  cause  and  the  location  of  the  lesion — the  only  de- 
cisive information  usually  obtainable  before  operation.    It  is  only  by  such 


♦Published  in  Surgery,  Gynecology  and  Obstetrics,  October,  1909. 


750  CHRONIC  PELVIC  INFLAMMATION 

careful  classification  of  the  cases  before  operation  and  careful  bacteriologic 
examination  after  operation,  that  a  useful  classification  can  be  established 
and  errors  gradually  eliminated. 

The  lessons  to  be  drawn  from  the  consideration  of  the  cases  of  the  gono- 
coccic  class  (clinical)  may  be  stated  briefly  under  three  heads,  as  follows: 

Reliability  of  the  Diagnostic  Points  Available  before  Operation.  From  the 
cases  here  cited,  wliich  are  typical  of  the  hundreds  belonging  to  this  class, 
it  is  evident  that  the  two  points  mentioned  (the  apparent  cause  and  the  loca- 
tion of  the  lesion)  may  be  depended  upon  to  eliminate  the  virulent  strepto- 
coccal cases.  Where  these  two  clinical  signs  agreed,  bacteriological  examina- 
tion of  the  pus  found  showed  either  the  gonococcus  or  absence  of  bac- 
teria, with  but  one  exception.  This  exceptional  case  was  rather  acute  and 
appeared  gonorrhoeal.  The  trouble  began  shortly  after  marriage  with  a  puru- 
lent vaginal  discharge  and  local  irritation.  The  discharge  was  not  examined 
bacteriologically.  An  adnexal  mass  appeared  on  each  side  and  extended  into 
the  cul-de-sac.  The  pus  pockets  in  the  pelvis  were  evacuated  by  vaginal  in- 
cision. Pus  was  found  in  the  cul-de-sac  and  in  both  tubes.  It  was  supposed 
to  be  gonorrheal.  Bacteriologic  examination  showed  pneumococci  in  abund- 
ance, but  no  gonoccoci.  In  the  cases  where  the  two  points  did  not  agree,  there 
were  various  bacteriological  findings.  In  uncertain  cases  the  location  of  the 
lesion  was  principally  depended  upon  for  classification.  Except  where  the 
trouble  was  clearly  from  puerperal  sepsis,  a  marked  tubo-ovarian  mass  with- 
out parametrial  involvement  admitted  the  case  to  this  clinical  class.  In  no 
instance  did  such  a  case  show  streptococci. 

In  the  cases  due  to  puerperal  sepsis  great  care  should  be  exercised  in  exclud- 
ing streptococci  before  admitting  the  case  to  the  gonococcic  clinical  class. 
The  apparent  location  of  the  lesion  helps,  but  can  not  be  depended  upon  en- 
tirely in  these  puerperal  cases.  A  few  cases  showing  streptococci  presented 
masses  at  first  supposed  to  be  purely  adnexal.  ]\Iost  of  these,  however,  on  more 
thorough  examination  at  the  time  of  operation,  jhowed  that  the  process  was 
located  partly  in  the  connective  tissue.  Streptococcal  pyosalpinx  without 
associated  parametritis  is  certainly  very  rare.  Miller,  who  reported  a  number 
of  streptococcal  infections  and  investigated  bacteriologically  more  than  a  hun- 
dred cases  of  pelvic  inflammation  at  Johns  Hopkins  Hospital,  stated  that  he 
had  never  encountered  a  frank  pyosalpinx  due  to  the  streptococcus.  White- 
side and  Walton,  in  a  series  of  thirty  cases  of  pyosalpinx  examined  for  bacteria, 
found  the  streptococcus  in  three,  but  the  question  of  coincident  parametrial 
involvement  does  not  seem  to  have  been  investigated.  In  a  series  of  106  eases 
of  suppurative  salpingitis,  Menge  demonstrated  the  streptococcus  in  4,  but 
nothing  definite  is  said  as  to  the  parametrial  involvement  in  these  cases. 

Persistence  of  Virulence.  In  the  clearly  gonococcic  cases  the  bacteria  were 
found  to  be  absent  or  attenuated,  as  a  rule  within  two  to  four  months  after 
infection.  In  some  cases  gonococci  were  found  after  several  months  or  a  year 
or  even  several  years,  but  they  had  lost  their  virulence.  Hartman  and 
Morax  state  that  all  their  specimens  showing  gonococci  were  from  patients 


STREPTOCOCCIC  INFLAMMATORY  MASSES  751 

with  rather  recent  inflammation,  the  duration  of  the  trouble  varying  from 
three  weeks  to  four  months,  and  averaging  four  to  five  weeks. 

Gonocoeei  may  die  and  disappear  within  a  few  weeks.  In  two  cases  de- 
tailed, where  examination  of  the  pus  showed  it  to  be  sterile,  the  duration  of 
the  trouble  was  only  two  months  in  one  case  and  five  weeks  in  another. 
Gonococcic  pus  confined  in  the  tube  may  become  sterile  in  six  or  eight  weeks, 
but  it  may,  on  the  other  hand,  continue  active  for  a  considerably  longer 
time.  Radical  operation,  therefore,  should  ordinarily  be  postponed  to  at  least 
three  months  from  the  onset  of  the  trouble. 

Why  Wait  for  Sterilization  or  Attenuation  in  Gonococcal  Cases.  There  are 
two  reasons.  In  the  first  place,  a  considerable  proportion  of  the  pelvic  in- 
flammatory masses  disappear  without  operation  if  nature  is  given  a  chance 
for  three  or  four  months.  Many  cases  of  supposed  pyosalpinx  so  recover. 
The  expression  "supposed  pyosalpinx"  is  used  advisedly.  I  do  not  care  to 
enter  into  the  controversy  over  the  possibility  of  the  spontaneous  cure  of 
pyosalpinx,  hence  I  limit  my  statement  to  the  inflammatory  masses  supposed 
to  be  pyosalpinx,  of  which  undoubtedly  a  considerable  proportion  disappear 
when  nature  is  given  a  reasonable  chance. 

The  second  reason  for  waiting  for  automatic  sterilization  or  effective  atten- 
uation of  the  pus  within  the  quiescent  mass,  is  that  active  gonorrhoeal  pus  is 
by  no  means  harmless.  General  peritonitis  due  to  the  gonococcus  is  not  so 
rare  as  formerly  supposed.  ITunner  and  Harris  collected  eighteen  cases  sup- 
ported by  bacteriological  proof,  and  seven  of  these  patients  died.  They  found 
also  twenty-one  cases  in  which,  though  bacteriological  proof  was  lacking,  the 
clinical  evidence  indicated  strongly  that  the  peritonitis  was  gonococcal,  and 
five  of  these  patients  died.  Again,  peritonitis  is  not  the  only  danger  from 
operation  on  a  quiescent  but  still  active  collection  of  gonorrhoeal  pus.  Price 
reports  a  case  in  which  such  an  operation  caused  general  dissemination  of 
the  bacteria,  with  involvement  of  the  joints  and  endocardium  and  finally 
death  fifteen  days  after  the  operation.  There  was  no  evidence  of  peritonitis. 
A  number  of  cases  of  general  dissemination  of  the  gonococcus  have  been  re- 
ported. Hunner  cultivated  gonocoeei  from  the  blood  taken  from  the  arm  of  a 
patient  five  days  after  abdominal  section  for  supposed  gonococcal  peritonitis, 
and  in  a  fatal  puerperal  case  Harris  and  Dabney  demonstrated  gonocoeei  in 
the  valves  of  the  heart. 

Streptococcic  Class  (Clinical). 

The  distinguishing  characteristics  are  (1)  the  apparent  cause  of  the  trouble 
and  (2)  the  location  of  the  lesion. 

a.  Apparent  cause.  Nearly  all  the  streptococcic  inflammatory  masses  in  the 
pelvis  can  be  traced  to  sepsis  following  labor  or  miscarriage.  In  the  adult, 
streptococci  do  not  spontaneously  penetrate  the  non-puerperal  uterus.  Aside 
from  labor  or  miscarriage,  streptococcus  infection  may  be  due  to  curetment 
or  other  uterine  operation,  to  intra-uterine  application  or  sounding,  to  a  stem 
pessary,  to  abnormal  conditions  caused  by  cancer  or  fibroid,  or  chronic  in- 


752  CHRONIC  PELVIC  INFLAMMATION 

flammation.  If  a  pelvic  inflammatory  trouble  can  not  be  traced  to  one  of  the 
causes  above  mentioned,  it  is  almost  certainly  not  streptococcic.  In  taking 
the  history,  care  must  be  exercised  not  to  miss  an  early  miscarriage  or  an 
intra-uterine  treatment.  Care  must  be  taken  also  to  trace  the  trouble  back 
to  its  very  beginning,  otherwise  an  exacerbation  remote  from  the  casual  mis- 
carriage or  labor  may  be  mistaken  for  the  beginning  of  the  trouble. 

On  the  other  hand,  not  all  puerperal  cases  are  streptococcic.  About  25  per 
cent  of  puerperal  infections  are  gonococcal.  They  are  usually  of  a  mild  type 
and  subside  quickly,  but  it  must  be  kept  in  mind  also  that  other  puerperal 
infections  (staphylococcic  and  even  streptococcic)  may  run  a  mild  course. 
Consequently  the  mildness  of  the  preceding  septic  attack  must  not  be  given 
too  much  weight.  Outside  of  external  evidences  of  gonorrhoea  (about  the 
vulva  or  in  the  discharge),  most  dependence  is  to  be  placed  on  the  location  of 
the  lesion.  Streptococcus  lesions  are  usually  parametrial,  while  gonococcus 
lesions  are  usually  tubo-ovarian. 

Another  complicating  factor  in  these  puerperal  cases  is  that  there  may  be 
a  mixed  infection,  causing  both  kinds  of  lesions  to  be  present.  Stone  and 
McDonald  reported  such  a  case.  This  case  furnished  also  a  beautiful  and 
striking  illustration  of  the  fact  that  the  gonococcus  spreads  by  way  of  the 
mucous  membrane  and  the  streptococcus  by  way  of  the  connective  tissue. 
The  gonococci  occupied  the  right  tube  and  extended  thence  into  the  peritoneal 
cavity,  while  the  streptococci  occupied  the  right  broad  ligament  and  extended 
thence  into  the  peritoneal  cavity,  where  the  two  forms  of  bacteria  met.  An- 
other possibility  in  these  puerperal  cases  is  that  the  two  forms  of  bacteria 
may  be  mixed  in  one  lesion — e.  g.,  in  a  pyosalpinx.  This  is  evidently  very 
rare,  but  it  has  occurred,  and  the  possibility  of  it  should  make  us  always  sus- 
picious of  a  post-puerperal  inflammatory  mass  wherever  located.  In  such  a 
case  the  evidences  for  and  against  the  presence  of  streptococci  should  be  most 
carefully  canvassed  before  deciding  to  subject  the  patient  to  abdominal  section. 

b.  Location  of  the  lesion.  A  chronic  lesion  in  the  pelvis  of  streptococcic 
origin  is  nearly  always  in  the  connective  tissue  (parametrium).  Unlike  tliQ 
gonococcus,  the  streptococcus  does  not  progress  along  the  mucosa  into  the 
tube,  but  penetrates  the  wall  of  the  uterus  and  extends  into  the  connective 
tissue  (Fig.  658).  It  not  infrequently  extends  from  the  connective  tissue 
to  the  peritoneum,  causing  peritonitis.  Of  course,  in  exceptional  eases  strep- 
tococci may  pass  from  the  uterus  into  the  tube,  but  in  such  cases  they 
are  likely  to  pass  on  through  the  tube  and  cause  fatal  peritonitis.  Conse- 
quently, in  the  streptococcic  eases  that  survive  the  acute  attack,  and  come 
later  for  treatment  for  an  inflammatory  mass,  the  lesion  nearly  always  in- 
volves the  connective  tissue  (parametrium).  As  before  mentioned,  Menge 
found  the  streptococcus  in  four  cases  of  pyosalpinx,  while  Whiteside  and 
Walton  found  it  in  three,  but  parametritis  was  not  excluded.  The  last  men- 
tioned authors  endeavored  to  produce  streptococcus  salpingitis  experi- 
mentally by  injecting  into  the  uterus  in  rabbits  pure  cultures  of  streptococci 
and  also  mixed  cultures  of  streptococci  and  staphylococci.   In  no  instance  did 


STREPTOCOCCIC  INFLAMMATORY  MASSES 


753 


salpingitis  result.  One  rabbit  died  of  acute  streptococcus  septicaemia,  while 
the  others  simply  developed  a  purulent  vaginitis  for  a  few  days  and  then  re- 
covered, and  when  replaced  in  the  rabbit  pen  became  pregnant  and  bore  lit- 
ters of  six  rabbits  each.  Miller,  in  the  bacteriological  examination  of  127 
cases  of  pelvic  inflammation,  found  the  streptococcus  7  times,  but  in  no  case 
was  the  lesion  a  pyosalpinx  alone.  There  are  very  few  exceptions  to  the  rule 
that  streptococcal  masses  in  the  pelvis  are  parametrial  in  whole  or  in  part. 

Are  all  parametrial  inflammatory  masses  streptococcic?  Nearly  all.  That 
parametrial  suppuration  is  usually  due  to  the  streptococcus  is  substantiated 
by  Rosthorn,  Bumm,  Doleris,  and  Bourges,  "West,  Cullingworth  and  others. 
Hartman  and  Morax  found  it  in  21  cases    of  parametrial  abscess.    In    every 


Fig.  658.  Streptococcal  Infection  in  Uterus  and  Resulting  Lesion.  Streptococcal  inflammation  extends 
through  the  uterine  wall  into  the  connective  tissue  (as  indicated  in  left  side),  forming  a  mass  in  the  broad  liga- 
ment. 

such  ease  operated  on  by  Fritsch  the  streptococcus  was  found  to  be  the  cause. 
It  is  only  occasionally  that  staphylococci  and  other  bacteria  are  found  either 
alone  or  associated  with  the  streptococcus.  As  parametrial  inflammation 
is  nearly  always  due  to  the  streptococcus,  every  case  presenting  a  para- 
metrial mass  should  be  placed  in  the  streptococcic  class  until  it  is  definitely 
proven  to  be  due  to  some  other  cause. 

The  distinguishing  characteristics  of  a  parametrial  mass  (chronic)  are : 
(a)  its  situation  in  the  connective  area,  usually  in  the  broad  ligament;  (b) 
its  low  situation  in  relation  to  the  uterus,  often  coming  far  down  beside  the 
cervix;  (c)  its  intimate  blending  with  the  uterine  wall,  as  though  it  were 
a  part  of  the  same;  (d)  its  intimate  blending  with  the  pelvic  wall,  as  though 
it  were  an  outgrowth  from  that  structure;  and  (e)  its  hardness,  often  being 


754  CHRONIC    PELVIC  INFLAMMATION 

SO  hard  as  to  simulate  a  cartilaginous  or  bony  tumor  growing  from  the  pelvic 
wall.  A  tubo-ovarian  mass,  on  the  other  hand,  is  distinguished  by  its  being 
situated  high  in  the  tubo-ovarian  region,  or  prolapsed  into  the  cul-de-sac ; 
by  its  not  blending  so  intimately  with  the  uterine  wall,  a  distinct  groove 
usually  marking  the  point  where  the  two  come  in  contact;  by  its  not  blend- 
ing so  closely  with  the  pelvic  wall ;  by  its  presenting  to  the  examining  finger 
a  portion  of  the  rounded  outline  of  the  tube  or  ovary ;  and  by  absence  of  the 
cartilaginous  hardness  often  seen  in  chronic  parametrial  masses. 

In  the  article  previously  mentioned  (page  749)  I  gave  the  details  of  a  series 
of  cases  of  the  streptococcic  class  (clinical),  showing  the  two  principal  diag- 
nostic points  before  operation,  the  interval  of  time  from  infection  to  opera- 
tion, the  bacteria  found  at  operation  and  the  degree  of  virulence  (as  indicated 
by  the  result  of  the  operation). 

From  this  series  of  cases  of  the  streptococcic  class  (clinical)  the  following 
facts  may  be  adduced : 

Reliability  of  the  Two  Diag-nostic  Points  Available  before  Operation.  When 
the  history  showed  that  the  trouble  originated  from  labor  or  abortion  and 
the  examination  showed  a  well  marked  parametritis,  streptococci  were  found 
in  every  case  except  one.  This  one  exception  (ease  16)  was  Hunner's  case, 
and  he  was  not  altogether  satisfied  with  the  bacteriologic  examination,  but 
stated  that  he  regarded  the  case  as  streptococcal  in  spite  of  the  negative 
findings. 

When  the  two  points  do  not  agree,  then  the  principal  weight  should  be 
given  to  the  location  of  the  lesion.  But  not  a  sufficient  number  of  carefully 
observed  cases  has  accumulated  to  define  accurately  how  great  a  dependence 
may  be  placed  on  the  location  of  the  lesion  in  these  uncertain  cases.  This  is 
a  point  to  be  further  investigated.  For  the  present  these  uncertain  cases 
should  be  considered  with  great  care  in  order  that  no  streptococcic  case  be 
allowed  to  slip  into  the  gonococcic  (abdominal  section)  class. 

Persistence  of  Virulence.  The  virulence  of  the  streptococcus  persists  in- 
definitely. Miller  reports  one  case  in  which  the  bacteria  persisted  for  six 
years  and  another  in  which  they  persisted  for  twelve  years.  IMartin  states 
that  streptococci  have  been  found  fully  virulent  in  a  pelvic  inflammatory 
mass  after  nineteen  years.  In  one  instance  (case  19)  streptococci  apparently 
disappeared  in  six  months,  but  the  pus  also  disappeared.  The  case  was  one 
of  severe  sepsis  following  labor.  On  the  eighth  day  vaginal  incision  into  a 
pelvic  abscess  evacuated  pus  containing  streptococci.  Six  months  later,  a 
mass  persisting,  a  A^aginal  incision  was  made  into  the  cul-de-sac  and  the  mass. 
No  pus  was  found,  but  there  was  serous  fluid  showing  staphylococci  alone. 

Automatic  sterilization  of  a  streptococcus  abscess  is  perhaps  possible,  but  it 
is  so  rare  that  it  is  not  to  be  counted  on.  A  streptococcal  mass  in  the  pelvis 
is  always  dangerous,  and  abdominal  section  for  the  same  at  any  time  is  likely 
to  be  followed  by  a  fatal  peritonitis.  The  cases  tabulated  in  the  article  men- 
tioned give  striking  proof  of  the  seriousness  of  intra-peritoneal  operation  in 
these  cases. 


OPERATION  FOR  INFLAMMATORY  MASSES  755 

Character  of  Operation.    The  only  safe  way  to  operate  for    streptococcal 

pus  collections  is  by  the  extra-peritoneal  method.  If  possible,  the  pus  collec- 
tion should  be  reached  and  evacuated  per  vaginam.  If  this  can  not  be  accom- 
plished, it  may  be  practicable  to  drain  the  abscess  by  extra-peritoneal  opera- 
tion above  Poupart's  ligament,  as  was  done  in  some  of  the  cases  mentioned. 
Intra-peritoneal  operation  in  these  cases  should  be  undertaken  only  when 
the  patient's  life  is  threatened  by  the  severity  of  the  inflammation  and  it  is 
impossible  to  reach  the  mass  in  a  less  dangerous  way. 

Conclusions. 

1.  In  more  than  half  of  the  cases  of  chronic  suppuration  in  the  pelvis  the 
pus  is  sterile  at  the  time  of  operation,  showing  that  sterilization  of  the  in- 
fected focus  takes  place  automatically  within  a  reasonable  time  in  the  ma- 
jority of  cases. 

2.  Abdominal  removal  of  the  mass  while  the  bacteria  are  active  and  viru- 
lent results  in  fatal  peritonitis  or  localized  infection  in  many  of  the  cases. 
Abdominal  removal  of  the  mass  after  the  bacteria  are  dead  or  greatly 
attenuated  is  almost  never  followed  by  infection,  even  though  there  is  ex- 
tensive escape  of  pus  into  the  pelvis. 

Hence  abdominal  operation  for  a  chronic  inflammatory  mass  in  the  pelvis 
should  not  be  undertaken  before  the  period  of  probable  sterilization,  except 
in  those  rare  cases  in  which,  in  spite  of  palliative  measures,  the  patient's  life 
is  threatened  by  the  severity  of  the  inflammation  and  the  infected  focus  can 
not  be  satisfactorily  drained  extra-peritoneally. 

3.  The  time  required  for  the  death  of  the  bacteria  or  effective  attenuation 
of  the  same  varies  greatly  in  the  different  cases.  The  persistence  of  virulence 
depends  largely  upon  the  character  of  the  infection.  The  two  infections  con- 
cerning which  definite  information  has  accumulated  as  to  persistence  of 
virulence  are  the  gonococcal  and  the  streptococcal. 

In  the  gonococcal  cases  the  bacteria  are  dead  or  attenuated  to  practical 
sterility  within  three  or  four  months  from  the  beginning  of  the  trouble.  In 
such  cases  abdominal  section  may  be  safely  undertaken  after  this  period.  In 
the  streptococcus  cases,  on  the  other  hand,  the  bacteria  live  and  retain  their 
%arulence  indefinitely.  In  some  cases  there  seems  to  be  a  diminution  in  the 
virulence,  but  this  is  erratic  and  not  to  be  depended  upon.  Abdominal  sec- 
tion for  a  mass  of  streptococcus  origin  is  never  safe.  Such  an  operation  at 
any  time,  even  years  after  the  infection,  is  liable  to  be  followed  by  fatal 
peritonitis. 

4.  These  two  classes  may  be  distinguished  before  operation  in  most  cases, 
the  distinguishing  characteristics  of  each  being  found  in  the  apparent  cause 
of  the  trouble  and  the  location  of  the  lesion,  as  already  explained,  in  detail. 

5.  What  is  the  preferable  time  for  abdominal  operation  for  a  chronic  in- 
flammatory mass  in  tlie  pelvis? 

a.  In  a  case  that  is  clearly  gonococcic  (agreement  on  the  two  points — the 
apparent  cause  of  the  trouble  and  the  location  of  the  lesion)  abdominal  opera- 


756  '  CHRONIC    PELVIC  INFLAMMATION 

tion  may  be  considered  safe  after  three  or  four  months  from  the  onset  of  the 
trouble.  If  after  this  time  the  mass  is  a  source  of  serious  irritation  in  spite 
of  palliative  treatment,  it  should  as  a  rule  be  removed.  On  the  other  hand, 
if  there  is  marked  improvement,  it  is  better  to  wait,  as  nature  may  bring 
about  recovery  without  operation. 

b.  In  a  case  that  is  clearly  streptococcic  (agreement  on  the  two  points) 
abdominal  section  is  never  safe.  Even  where  the  temperature  and  pulse  are 
normal  and  everything  quiescent,  intra-peritoneal  operation  for  the  mass  is 
liable  to  cause  the  patient's  death  from  streptococcal  peritonitis. 

c.  In  a  case  that  is  doubtful  (disagreement  on  the  two  points)  a  most  careful 
study  should  be  made  of  all  the  features  of  the  case  and  every  helpful  diag- 
nostic method  should  be  brought  into  use  to  aid  in  reaching  a  positive  con- 
clusion. No  intra-peritoneal  operation  should  be  undertaken  until  the  strep- 
tococcus is  excluded  with  reasonable  certainty.  In  a  doubtful  case  in  which 
the  abdomen  is  opened  on  the  supposition  that  the  mass  is  tubo-ovarian  and 
it  is  found  before  adhesions  are  much  disturbed  that  the  mass  is  principally 
in  the  connective  tissue  (parametritic),  the  route  of  attack  should  be  changed 
to  extra-peritoneal  (per  vagina  or  above  Poupart's  ligament)  and  the  abdomi- 
nal wound  closed.  Such  a  lesion  probably  contains  streptococci  and  the 
adhesions  of  omentum  and  bowel,  which  causes  the  deceptive  mass  high  in 
the  tubal  region,  constitute  nature's  barrier  between  the  virulent  bacteria 
and  the  peritoneal  cavity.  When  this  barrier  is  broken  down,  the  way  is 
opened  for  a  fatal  peritonitis. 

6.  There  are  three  reasons  for  calling  special  attention  to  this  subject: 
a.  A  matter  of  such  vital  importance  should,  I  think,  be  given  more  promi- 
nence in  text-books  and  in  instruction  to  students,  and  in  society  proceedings 
and  discussions  concerning  pus  collections  in  the  pelvis,  b.  Lives  are  still  be- 
ing sacrificed  by  operators  who  seem  unaware  of  the  great  danger  of  abdomi- 
nal operation  for  inflammatory  masses  following  puerperal  sepsis,  c.  Further 
investigation  (with  careful  recording  in  large  series  of  cases  of  the  apparent 
cause  of  the  trouble,  the  location  of  the  lesion,  the  interval  of  time  from  in- 
fection to  operation,  the  bacteriologic  findings,  and  the  result  of  operation) 
is  required,  that  the  definite  classification  of  the  cases  before  operation,  as 
above  indicated,  may  be  firmly  established  and  errors  eliminated. 

3.  Avoid  radical  operation  in  those  cases  in  which  the  examination  shows 
only  a  somewhat  thickened  and  tender  tube  (catarrhal  salpingitis),  or  a 
slightly  enlarged  and  sensitive  and  perhaps  prolapsed  ovary  (cystic  ovary)? 
or  adhesions  with  som-C  induration  and  fixation,  but  with  no  distinct  mass. 
Give  a  thorough  trial  to  the  non-operative  measures  previously  mentioned, 
with  such  additions  and  modifications  as  the  peculiarities  of  the  case  may  sug- 
gest. In  those  cases  in  which  all  signs  of  active  inflammation  have  subsided, 
leaving  only  adhesions  binding  the  uterus  or  ovary  in  abnormal  position  or 
distorting  the  tube,  much  benefit  may  sometimes  be  derived  from  pelvic  mas- 
sage, with  stretching  of  adhesions,  or  from  pressure  treatment,  or  from  the 
two  in  combination.    In  cases  with  troublesome  uterine  discharge   and  ex- 


PROGNOSIS  IN  CHRONIC  PELVIC  INFLAMMATION  757 

cessive  menstrual  flow  or  painful  menstruation,  thorough  dilatation  and 
curettage  is  advisable.  This  tends  to  diminish  the  discharge  and  menstrual 
suffering,  and  in  some  cases  it  has  a  decided  beneficial  effect  on  the  adjacent 
adnexal  trouble.  Furthermore,  it  gives  a  chance  for  a  thorough  examination 
under  anesthesia,  by  which  the  exact  condition  of  the  ovaries,  tubes  and 
uterus  can  be  more  accurately  determined.  In  cases  with  persistent  pain 
without  decided  palpable  lesion — i.  e.,  those  cases  in  which  the  nervous  ele- 
ment is  marked  and  in  Avhicli  the  affection  approaches  the  character  of  a 
neuralgia  or  neuritis — electricity  may  give  some  relief  (see  page  353).  It  is  in 
these  cases  also  that  a  tonic  regimen  (with  general  massage,  brush  rubs,  salt 
rubs,  etc.)  and  antineuralgic  remedies  are  especially  indicated,  and  often  pro- 
duce a  cure  with  little  or  no  local  treatment. 

Careful  study  should  be  made  of  the  patient  generally — of  all  the  organs. 
In  some  such  cases  it  will  be  found  that  the  principal  trouble  is  some  general 
disease  or  some  local  disease  in  another  portion  of  the  body,  the  pelvic  disor- 
der being  of  secondary  importance.  If  nothing  is  found  outside  the  pehas  to 
account  for  the  patient's  symptoms  and  all  other  measures  fail  to  relieve  the 
pelvic  distress,  open  the  abdomen  and  ascertain  the  exact  condition  of  the 
pelvic  organs  and  vermiform  appendix  and  then  correct,  as  far  as  possible, 
the  pathological  conditions  found. 

4.  In  the  operative  cases,  when  the  patient  is  under  forty  years  of  age  and 
the  pathological  condition  will  permit,  preserve  enough  ovarian  tissue  to  con- 
tinue menstruation  and  enough  Fallopian  tube  to  make  pregnancy  possible. 

In  those  cases  where  all  active  inflammation  has  disappeared,  leaving  only 
adhesions  and  exudate,  it  is  often  possible  to  preserve  in  place  part  of  an 
ovary  and  part  of  a  tube,  which  by  proper  treatment  may  continue  their  func- 
tions. 

This  conservative  work  is  a  comparatively  recent  development  of  pelvic  sur- 
gery, but  several  cases  of  pregnancy  have  already  been  reported  from  such, 
remnants  of  ovary  and  tube  preserved.  Even  if  pregnancy  does  not  take 
place,  the  simple  fact  that  it  may  take  place — that  it  is  possible — leaves  the 
patient  in  a  much  better  frame  of  mind. 

If  the  uterus  must  be  removed,  one  ovary  at  least  should  be  preserved,  if 
it  is  not  diseased,  because  the  preservation  of  any  ovary,  or  even  part  of  an 
ovary,  tends  to  prevent  those  troublesome  nervous  symptoms  which  fre- 
quently accompany  the  artificial  menopause  and  which  sometimes  become 
serious. 

PROGNOSIS. 

What  are  the  ultimate  results  in  cases  of  chronic  pelvic  inflammation? 
What  answer  shall  be  given  to  the  patient  who  asks,  "Doctor,  will  the  pro- 
posed treatment  make  me  a  well  woman?" 

Now,  the  results  differ  much  in  various  cases,  and  in  order  to  answer  this 
question  in  a  comprehensive  way  it  is  necessary  to  divide  the  cases  into  two 
great  classes— the  first  including  those  cases  in  which  the  symptoms  are  ap- 


758  CHRONIC  PELVIC  INFLAMMATION 

parently  all  dependent  on  an  evident  lesion,  and  the  second  including  those 
eases  in  which  there  are  symptoms  the  cause  of  which  is  not  clear. 

1.  "Where  there  is  a  marked  lesion  in  the  pelvis  of  such  nature  as  to  account 
for  all  the  symptoms  and  the  patient  is  otherwise  in  good  health,  proper 
treatment  will  in  all  probability  effect  a  cure.  The  treatment  must,  of  course, 
be  carried  out  carefully  and  vigorously  according  to  the  indications  in  the 
particular  case.  And  in  any  case  it  will  extend  over  several  months,  for  even 
in  the  cases  in  which  the  pelvic  legion  can  be  largely  removed  by  operation 
the  patient  will  require  careful  after-treatment  to  put  her  in  good  health. 

As  to  the  promises  you  make  to  the  patient,  be  careful.  You  must  give  the 
patient  all  the  encouragement  possible,  for  encouragement  helps  in  the  cure, 
but  you  must  not  commit  yourself  in  such  a  way  that,  if  something  unfore- 
seen prevents  a  cure,  you  will  be  in  the  position  of  having  promised  some- 
thing that  you  can  not  give.  This  subject  of  prognosis  and  promises  to  pa- 
tients is  one  of  the  most  trying  in  medical  and  surgical  work.  Most  diseases 
may,  by  treatment,  be  either  cured  or  improved  so  much  that  the  patient 
thinks  them  cured.  Advertising  quacks  take  advantage  of  this  fact  and  prom- 
ise certain  cure  in  all  cases — ^"Cure  guaranteed."  Some  of  the  patients  are, 
no  doubt,  really  cured,  and  others  are  so  much  improved  for  the  time  being 
that  they  think  themselves  cured  and  shout  accordingly,  while  those  who  are 
not  improved  are  so  ashamed  of  having  gone  to  a  quack  that  they  say  nothing 
about  it,  and  so  the  imposter  goes  on  Avithout  hindrance.  But  the  reputable 
physician  must  be  careful  with  his  promises.  We  deal  in  facts,  not  deceptions. 
Our  duty  is  to  employ  the  best  possible  means  for  the  relief  of  the  patient 
and  the  cure  of  her  disease,  and  at  the  same  time  to  give  her  all  the  encour- 
agement possible.  There  are,  hoAvever,  so  many  uncertainties  that  enter  into 
the  problem  that  it  is,  in  most  cases,  best  to  say  but  little  about  the  prog- 
nosis unless  the  patient  asks  directly  concerning  it.  If  the  patient  requests 
a  definite  statement  as  to  just  AA''hat  chance  she  has  of  permanent  relief,  prom- 
ise her  all  that  the  circumstances  Avill  Avarrant — giving  the  most  favorable 
construction  to  all  phases — but  ahvays  Avith  this  proviso,  said  to  the  patient 
herself  or  to  a  near  relative,  that  in  spite  of  the  best  treatment  there  is  a  pos- 
sibility of  the  development  of  conditions  which  would  give  a  different  result. 
This  caution  in  promises  is  particularly  important  in  surgical  work,  for  many 
patients  are  prone  to  expect  from  an  operation  the  cure  of  every  existing  dis- 
turbance, Avhether  it  comes  AAdthin  the  scope  of  the  operation  or  not. 

2.  In  cases  where  there  is  no  marked  pelvic  lesion,  or  Avhere,  in  addition  to 
a  marked  lesion,  there  are  symptoms  that  are  not  accounted  for  by  the  pehdc 
disease,  the  prognosis' is  uncertain.  The  fact  that  there  are  symptoms  without 
apparent  cause  means  that  there  is  a  hidden  factor  in  the  case,  and  that  hid- 
den factor  may  continue  to  cause  much  trouble  after  the  obvious  lesion  is  re- 
moved. Promise  as  much  as  you  can  count  on  safely,  but  no  more.  Sometimes 
very  serious  or  troublesome  symptoms  will  subside  after  correction  of  3,n  ap- 
parently slight  pelvic  disorder.  Many  symptoms,  particularly  nervous  symp- 
toms, apparently  not  closely  connected  with  the  pelvic  disease,  disappear  ojq 


PROGNOSIS  IN  CHRONIC  INFLAMMATORY  MASSES  759 

the  cure  of  the  pelvic  disorder,  much  to  the  delight  of  the  patient  and  of  the 
physician.  On  the  other  hand,  many  symptoms,  particularly  nervous  symp- 
toms, apparently  due  to  well  marked  pelvic  disease,  persist  after  the  removal 
of  the  disease,  much  to  the  disappointment  of  the  patient  and  the  physician. 
In  some  of  these  cases  the  troublesome  symptoms  had  no  connection  -with  the 
pelvic  trouble,  but  were  caused  by  some  entirely  separate  disorder.  In  other 
cases  the  nervous  symptoms  were  really  caused  by  the  pelvic  disease,  but 
through  long  continuance  of  the  irritation  there  was  produced  in  the  nervous 
system  a  pathological  condition  capable  of  persisting  long  after  the  removal 
of  the  causative  lesion. 

Then,  again,  there  are  certain  cases  of  hereditary  tendency  to  insanity  in 
which  a  serious  pelvic  disease  is  sufficient  to  cause  a  breakdown  and  the  de- 
velopment of  mental  disorder.  In  such  a  ease,  though  you  may  hope  for  im- 
provement, you  can  not  promise  much,  for  the  mental  disorder,  once  excited, 
may  persist  in  spite  of  the  removal  of  the  exciting  cause. 

Again,  occasionally  a  patient  with  this  tendency  to  mental  disturbance  will 
get  along  very  well  until  subjected  to  operation  for  some  disease,  pehdc  or 
otherwise,  and  then  the  added  strain  of  the  operation  upsets  the  mental  bal- 
ance and  she  becomes  insane. 

These  are,  of  course,  exceptional  circumstances.  I  mention  them  simply  to 
show  how  many  things  the  physician  must  think  of — what  a  broad  view  of 
the  subject  he  must  take — in  giving  a  prognosis  as  to  the  ultimate  result. 


760 


CHAPTER  XL 

OTHER  AFFECTIONS 

of  Fallopian  Tubes,  Pelvic  Peritoneum  and  Pelvic  Connective  Tissue. 

PELVIC  TUBERCULOSIS. 

Pelvic  tuberculosis  is  tuberculosis  of  the  Fallopian  tubes  or  pelvic  perito- 
neum or  ovaries,  or  of  all  these  structures  together.  It  is  known  also  as 
"tubercular   salpingitis,"    "tubercular   pelvic   peritonitis"    and   "tubercular 

oophoritis." 

ETIOLOGY. 

The  same  factors  are  operative  here  as  in  tubercular  lesions  elsewhere — 
namely,  tubercle  bacilli  and  lowered  tissue  resistance.  As  to  how  the  tubercle 
bacilli  reach  these  deep-seated  structures,  and  v/hy  they  locate  here,  is  an  in- 
teresting story  and  one  not  yet  completed. 

The  following  factors  have  a  bearing  on  the  etiology  of  the  affection : 

1.  Tubercular  lesions  in  distant  organs — for  instance,  in  the  lungs.  From 
these  distant  lesions  the  bacilli  get  into  the  blood  stream  and  are  carried  to 
various  parts  of  the  body,  frequently  to  the  Fallopian  tubes.  In  some  cases 
the  FaUopian  tube  lesions  constitute  the  only  secondary  lesion  found. 

2.  Tubercular  lesions  in  adjacent  organs,  as  the  bladder,  rectum,  intestines 
or  abdominal  peritoneum.  The  most  frequent  are  tubercular  appendicitis  and 
tubercular  ulceration  of  the  small  intestine.  In  the  former  the  process  ex- 
tends directly  along  the  peritoneal  surface  to  the  pelvic  peritoneum  and  the 
Fallopian  tubes  and  the  ovaries.  In  the  latter  there  may  be  an  adhesion  be- 
tween the  irritated  peritoneal  surface  over  a  tubercular  ulcer  of  the  in- 
testine and  the  surface  of  a  tube  or  ovary,  or  of  the  pelvic  peritoneum.  After 
adhesion  the  process  gradually  extends  through  the  intervening  tissue. 

In  tuberculosis  of  the  bladder  or  rectum,  penetration  of  intervening  tissue 
may  take  place,  thus  bringing  the  bacilli  in  contact  with  the  structures  under 
consideration. 

3.  Occasionally  the  tubercular  infection  may  come  by  way  of  the  genital 
tract  from  lesions  lower — for  example,  from  tuberculosis  of  the  uterus,  or  of 
the  vagina,  or  of  the  vulva.  This,  however,  is  very  rare,  the  process  usually 
extending  from  above  downward  instead  of  from  below  upward. 

PATHOLOGY. 

The  cases  of  pelvic  tuberculosis  may  be  grouped  roughly  into  two  classes 
(A)  those  in  which  the  peritoneum  is  principally  involved  and  (B)  those  in 
which  the  process  is  located  principally  in  one  or  both  Fallopian  tubes. 


FORMS   OF  PELVIC  TUBERCULOSIS 


761 


(A.)     Peritoneal  Tuberculosis. 

Peritoneal  tuberculosis  begins  as  a  deposit  of  fine  tubercles  in  the  pelvic 
peritoneum.  This  deposit  may  take  place  slowly  or  rapidly.  If  it  takes  place 
slowly,  the  disturbance  may  be  slight  and  the  symptoms  hardly  noticeable.  If 
the  deposit  takes  place  rapidly,  it  produces  the  condition  known  as  acute 
miliary  tuberculosis  of  the  pelvic  peritoneum.  In  this  marked  miliary  form 
the  whole  pelvic  peritoneum  covering  the  various  structures  may  be  closely 
studded  with  the  tubercles  (Fig.  659). 

This  produces  pelvic  peritonitis.  The  peritoneum  about  the  deposits  is  in- 
jected, reddened  and  lacks  its  normal  luster.  Ascitic  fluid  appears  and  the 
fluid  may  have  a  bloody  tinge.  The  fluid  may  be  free  in  the  peritoneal  cavity, 
with  no  limiting  adhesion,  or  there  may  be  adhesions  that  form  pockets  in 
which  the  fluid  is  confined  (encysted  fluid).  In  this  form  the  tubercular  proc- 
ess is  usually  widespread,  involving  a  large  part  of  the  general  peritoneum. 
The  intestinal  coils  may  be  adherent  to  each    other    or    to  the  parietal  peri- 


Fig.  659.     Pehic  Tuberculosis— Peritoneal  Form.     {Kelly— Operative  Gynecology.) 

toneum,  or  to  all  the  pelvic  structures.  The  adhesions  are  usually  frail  and 
bleed  easily  upon  being  separated,  but  the  bleeding  soon  stops.  On  account  of 
the  tendency  to  peritoneal  efi'usion  in  this  miliary  form  of  tuberculosis,  the 
adhesions  are  not  usually  extensive. 

After  development  to  this  stage  the  tubercles  may  pursue  either  of  two 
courses. 

a.  The  tubercles  may  undergo  fibroid  change.  The  active  symptoms  disap- 
pear, the  fluid  is  absorbed,  and  the  diseased  areas  become  scar  tissue.  This  is 
called  "fibroid  tuberculosis."  It  is  a  limitation  of  the  tubercular  process  and 
constitutes  a  temporary  cure  of  the  disease. 

b.  Instead  of  the  tubercles  passing  into  this  quiescent  condition,  they  may 
spread  and  coalesce  and  break  doAvn,  and  thus  the  process  becomes  pro- 
gressively destructive.  The  tubercular  areas  undergo  necrosis  and  caseation, 
dense  adhesions  take  place,  collections  of  tubercular  pus  form,  and  all  the 
pehdc  structures  become  bound  together  into  an  irregular  mass,  with  broken- 
down  tubercular  lesions  scattered  throughout. 


762 


PELVIC  TUBERCULOSIS 


(B.)     Tubal  Tuberculosis. 

In  tuberculosis  of  the  Fallopian  tubes  the  process,  instead  of  appearing  first 
in  the  peritoneum,  may  start  in  the  interior  of  a  tube. 

In  this  situation  three  forms  are  recognized — (a)  miliary  tuberculosis, 
(b)   chronic  fibroid  tuberculosis  and   (c)   chronic  diffuse  tuberculosis. 

a.  Miliary  tuberculosis  of  a  Fallopian  tube  presents  the  same  character- 
istics as  miliary  tuberculosis  of  other  mucous  membranes — ^that  is,  there 
are  fine  tubercles  scattered  beneath  the  epithelium  and  not  yet  broken  down. 
Owing  to  the  structure  of  the  tube,  the  miliary"  tubercles  readily  escape  obser- 
vation unless  the  removed  tube  is   examined  miscroscopically.     This   form 


Fig.  660.     Pehic  Tuberculosis — Tubal  Form.     (Kelly — Operative  Gynecology.) 


of  tuberculosis  may  give  rise  to  but  few  symptoms,  and  may  cause  so  little 
disturbance  that  there  is  no  suspicion  of  serious  disease. 

b.  If  these  tubercles  fail  to  pass  on  to  the  stage  of  caseation,  but  instead 
become  surrounded  by  a  large  amount  of  connective  tissue  and  pass  into  a 
quiescent  state,- we  have  the  condition  known  as  "fibroid  tuberculosis  of  the 
tube."  The  tube  is  someAvhat  thickened,  and  hardened  and  enlarged  by  the 
infiltration,  but  there  is  little  or  no  breaking  doAvn  of  the  lesions. 

c.  If,  on  the  other  hand,  the  tubercles  progress  to  the  stage  of  caseation 
and  break  down,  there  results  the  condition  known  as  "chroniC'  diffuse 
tuberculosis  of  the  tubes."  The  tube  is  disorganized  and  contains  a  col- 
lection of  caseous  tubercular  material   (Fig.  660). 


SYMPTOMS  AND  DIAGNOSIS  763 

The  appearance  of  the  tube  varies  of  course  witli  the  severity  of  the  disease. 
In  advanced  cases  the  tube  is  greatly  enlarged  and  on  cutting  it  open  the 
yellow  broken  down  material  is  seen — the  so-called  "caseous  pus."  This 
varies  much  in  consistency,  being  in  some  cases  rather  thin  and  in  other 
semi-solid.  AVhen  this  is  removed,  the  mucosa  of  the  tube  is  seen  to  be 
studded  with  tubercles,  in  all  stages  of  breaking  down,  and  there  are  also 
irregular,  ragged  ulcers,  with  small  yellowish  tubercles  in  their  walls. 

When  the  peritoneal  surface  of  the  tube  also  is  involved,  it  is  studded  with 
small  tubercles  and  is  usually  adherent  to  some  of  the  surrounding  organs. 
Occasionally  the  tubercular  areas  undergo  calcification. 

Tubal  tuberculosis  is  also  one  of  the  common  causes  of  general  tuberculous 
peritonitis,  a  point  of  importance  which  will  be  further  considered  under 
treatment. 

Pelvic  tuberculosis  has  been  found  to  be  present  in  from  six  to  eight  per 
cent,  of  the  cases  of  abdominal  section  for  pelvic  inflammation,  but  in  only 
about  a  quarter  of  these  is  it  so  marked  as  to  be  easily  recognized.  In  the 
remaining  cases  it  is  recognized  only  by  microscopical  examination  of  sections 
of  the  tube. 

No  period  of  life  is  exempt  from  genital  tuberculosis.  It  has  been  found 
at  all  ages,  from  the  infant  of  a  few  months  to  the  aged  woman  past 
eighty.  But  the  period  of  life  in  which  it  occurs  most  frequently  is  from 
the  age  of  20  to  that  of  40  years — i.  e..  during  the  period  of  greatest  sexual 
activity. 

SYMPTOMS  AND  DIAGNOSIS. 

The  symptoms  of  pelvic  tuberculosis  are  much  the  same  as  those  of  chronio 
pelvic  inflammation.  In  fact  it  is  a  pehdc  inflammation  of  a  special  kind. 
In  a  large  per  cent,  of  the  cases  the  diagnosis  of  tuberculosis  is  made  only 
after  the  abdomen  has  been  opened,  the  operation  ha^dng  been  undertaken 
for  what  was  supposed  to  be  ordinary  pehdc  inflammation. 

In  not  a  few  cases,  however,  a  positive  diagnosis  of  tuberculosis  is  possible 
before  operation,  and  in  some  cases  it  is  easj''. 

The  conditions  that  point  to  pehdc  tuberculosis  are  as  follows : 

1.  Symptoms  of  chronic  pehdc  inflammation  in  a  girl  or  young  woman  who 
has  had  no  e^ddence  of  uterine  infection. 

2.  Gradual  onset  ^vithout  previous  uterine  disease,  and  persistent  progress, 
^vithout  the  periods  of  marked  improvement  usually  present  in  ordinary 
pelvic  inflammation. 

3.  Emaciation,  gradual  and  persistent,  without  a  corresponding  severity 
of  the  inflammatory  trouble. 

4.  E^ddences  of  tuberculosis  elsewhere.  :\rost  cases  of  pelvic  tuberculosis 
occur  in  patients  having  pulmonary  or  intestinal  tuberculosis. 

5.  Tuberculin  reaction.  In  a  doubtful  case  this  may  aid  materially  in  the 
diagnosis.  The  injection  method  or  the  cutaneous  test  may  be  employed. 
The  ophthalmic  test  is  dangerous  to  the  eye  and  had  best  be  avoided. 


764  EXTRA-UTERINE   PREGNANCY 


TREATMENT. 


If  there  are  no  contra-indicating  lesions  elsewhere,  the  affected  tubes  should 
be  extirpated,  preferably,  by  abdominal  section.  The  operation  should  be 
preceded  and  followed  by  antitubercular  remedies  and  regimen. 

If  there  are  marked  lesions  elsewhere,  or  if  the  local  trouble  has  advanced 
too  far  for  radical  operation,  employ  palliative  measures.  The  palliative 
measures  include  the  administration  of  antitubercular  remedies  internally, 
the  drainage  of  fluid  collections  by  operation  and  other  measures  mentioned 
under  chronic  pelvic  inflammation. 

In  some  cases  of  extensive  peritoneal  tuberculosis,  an  apparent  cure  has 
followed  simple  abdominal  section.  It  is  still  a  question  why  such  a  change 
for  the  better  should  sometimes  follow  the  mere  opening  of  the  abdomen  in 
these  cases,  but  the  fact  that  such  results  are  secured  has  been  demonstrated 
many  times,  and  patients  that  are  in  suitable  condition  should  be  given  this 
chance  for  improvement.  The  affected  tubes,  however,  should  always  be 
removed  when  possible. 

Pelvic  tuberculosis  often  eventuates  in  general  peritoneal  tuberculosis. 
General  tubercular  peritonitis  can  usually  be  traced  to  a  tubercular  appendi- 
citis, or  to  tubercular  salpingitis,  or  to  tubercular  ulceration  of  the  intestine. 
In  operating  for  tubercular  peritonitis  it  is  important  to  find  and  remove 
the  focus  if  it  can  be  done  without  too  much  traumatism.  Mayo  has  done 
great  service  in  insisting  on  this  and  in  demonstrating  the  marked  increase 
in  the  percentage  of  cures  resulting  therefrom. 


EXTRA=UTERINE  PREGNANCY. 

Extra-uterine  pregnancy  is  pregnancy  outside  of  the  uterine  cavity.  With 
few  exceptions  the  developing  embryo  is,  in  the  beginning,  located  in  the 
Fallopian  tube,  consequently  the  term  "tubal  pregnancy"  is  applicable  in 
most  cases.  The  developing  ovum  may  lodge  at  any  part  of  the  tube  (see 
Fig.  661). 

ETIOLOGY. 

The  cause  of  extra-uterine  pregnancy  is  some  interference  with  the  down- 
ward progress  of  the  fertilized  ovum.  The  ovum  and  spermatozoa  meet 
normally  in  the  tube,  and  after  fertilization  the  ovum  passes  along  the 
remainder  of  the  tube  and  into  the  uterus,  where  it  becomes  attached  and 
develops,  constituting  a  normal  pregnancy.  Now,  if  the  progress  of  the 
fertilized  ovum  is  interfered  with  so  that  it  remains  in  the  tube  and  develops 
there,  extra-uterine  pregnancy  is  the  result.  This  interference  with  the 
downward  progress  of  the  ovum  is  usually  due  to  some  obstruction  in  the 
narrow  proximal  portion  of  the  tube,  though  the  obstruction  may  be  situated 
anywhere  between  the  ovary  and  the  uterine  cavity.  The  tubal  obstruetioij 
must,  of  course,  not  be  so  marked  as  to  prevent  the  upward  progress  of  the 


PATHOLOGY  7g5 

spermatozoa;  consequently  extra-nterino  pregnancy  is  impossible  when  both 
tubes  are  completely  occluded  by  iuflaminatiou  or  other  process. 

The  conditions  which  interfere  more  or  less  with  the  downward  progress 
of  the  ovum  are  as  follows : 

1.  Mild  salpingitis.  Slight  iiiflammation  may  lead  to  destruction  of  the 
cilia.  The  action  of  the  cilia  is  sni)posed  to  be  necessary  to  the  normal  prog- 
ress of  the  ovum  from  the  abdominal  to  the  uterine  end  of  the  tube,  the 
peristaltic  action  of  the  tube  being  of  secondary  importance  and  not  sufficient 
in  itself  to  carry  the  ovum  along. 

Again,  such  inflammation  leads  to  swelling  of  the  tubal  mucosa  and 
mechanical  obstruction  in  the  narrow  portion  of  the  tube.  This  obstruction, 
while  not  marked  enough  to  prevent  the  upward  progress  of  the  active 
spermatozoa,  may  prevent  the  downw^ard  progress  of  the  passive  ovum. 

2.  Adhesions,  from  inflammation  originating  in  the  tube  or  elsewhere, 
may  so  distort  the  tube  by  bending  or  pressure  as  to  partially  obstruct  its 
lumen. 

3.  Tumors  within  the  tube  wall  or  arising  from  other  structures  may  by 
pressure  narrow  the  lumen  of  the  tube. 

4.  Malformations.  Abel  agrees  with  Freund  that  some  of  the  spiral  twists 
which  are  normally  present  in  the  tube  in  the  embryo  may  persist  to  adult 
life  and  cause  sufficient  obstruction  to  lead  to  extra-uterine  pregnancy.  Diver- 
ticula may  lead  off  from  the  lumen  of  the  Fallopian  tube.  If  a  fertilized  ovum 
lodges  in  one  of  these  blind  canals,  tubal  pregnancy  will  result.  There  may 
be  also  accessory  tubes.  These  are  usually  connected  to  the  normal  tube, 
but  sometimes  by  a  cord  only  without  any  lumen.  In  such  a  case,  if  a  fertilized 
ovum  enters  this  accessor}^  tube,  it  will  remain  there. 

A  rudimentary  tube  which  is  not  open  all  the  way  to  the  uterus  may  be 
entered  by  an  ovum  which  has  been  fertilized  by  a  spermatozoa  entering 
from  the  normal  tube  of  the  opposite  side.  The  fertilized  ovum  is,  of  course, 
stopped  at  the  impervious  portion  of  the  deformed  tube,  and  a  tubal  preg- 
nancy is  the  result.  Kelly  figures  an  interesting  case  in  which  this  same 
series  of  events  occurred  in  a  rudimentary  uterine  horn,  the  horn  being  so 
separated  from  the  remainder  of  the  uterus  that  it  resembled  part  of  the 
tube  (Fig.  409). 

PATHOLOGY. 

The  fertilized  ovum  may  lodge  at  any  part  of  the  Fallopian  tube,  as  show^n 
in  Fig.  661.  When  the  ovum  becomes  attached  to  the  tube  w^all,  certain 
changes  begin.  First,  there  is  marked  hyperemia,  which  leads  to  some  swell- 
ing of  the  structures  and  to  increased  growth  of  all  the  tissue  elements  of 
the  tube  wall.  In  the  mucosa  in  tubal  pregnancy  the  stroma  cells  enlarge 
and  become  decidua  cells,  though  they  do  not  become  so  large  or  so  closely 
packed  together  as  in  the  uterine  mucosa.  There  is  some  hypertrophy  of 
the  muscular  tissue  near  the  attachment  of  the  ovum.  Very  soon  there 
appear  certain  interesting  changes  that  have  a  bearing  on  the  early  rupture 
of  the  pregnant  tube.   As  the  fetal  elements  reach  into  the  tubal  tissues,  seek- 


766 


EXTRA-UTERINE  PREGNANCY 


ing  nourishment,  the  wall  of  the  tuBe  becomes  penetrated  by  wandering  cells 
called  "trophoblasts. "  These  trophoblast  cells  work  into  the  muscular  layer 
of  the  tube  and  weaken  it,  and  gradually  penetrate  all  the  way  through  the 
wall.  This  growth  of  fetal  elements  into  and  through  the  wall  of  the  tube 
causes  early  rupture  of  the  tube  and  serious  internal  hemorrhage. 

Pathologically  and,  in  a  measure,  clinically,  the  causes  may  be  divided  into 
the  following  classes : 

1.  Before  Rupture.  The  developing  embryo  with  its  membranes  is  still 
completely  surrounded  by  the  unbroken  tube. 

2.  Intraperitoneal  Rupture  with  Single  Moderate  Hemorrhage.  The  blood 
gravitates  into  the  cul-de-sac  of  Douglas.  Adhesions  bind  together  the 
structures  above,  thus  forming  a  roof  which  shuts  off  the  blood-filled  cul-de-sac 
from  the  remaining  part  of  the  peritoneal  cavity.  This  condition  is  known 
as  ''pelvic  hematocele"   (Fig.  662).     The  blood  may  be  gradually  absorbed 


Fig.  661.  Diagram  Representing  the  Sites  for  the  Various  Forms  of  Tubal  Pregnancy.  1,  Interstitial 
pregnancy.  2,  Isthmial  pregnancy.  3,  Ampullar  pregnancy.  4,  Infundibular  pregnancy.  5,  Tubo-ovariah 
pregnancy.     (Gilliam — Practical  Gynecology.) 


without  further  disturbance  or  the  hematocele  may  require  drainage,  as  de- 
scribed under  treatment.  The  very  early  embryo  with  membranes,  having  been 
completely  cast  off  from  its  point  of  nourishment,  perishes  and  is  usually 
absorbed  without  causing  further  trouble. 

3.  Intraperitoneal  Rupture  with  Repeated  Moderate  Hemorrhage.  The 
membranes  usually  remain  partially  attached  within  the  broken  tube,  and 
hence  the  extruded  embryo  continues  to  grow,  causing  trouble  later.  The 
first  hemorrhage  leads  to  peritoneal  exudate,  with  resulting  adhesions,  which 
bind  together  adjacent  structures.  Thus  the  blood  mass  and  broken  tube  and 
growing  embryo  are  surrounded  by  a  wall  of  exudate  and  adherent  intestine. 
This  wall  lessens  the  danger  temporarily.  But  after  a  few  days  or  a  few 
weeks  the  continued  growth  causes  further  rupture  of  the  tube  or  of  the 
other  limiting  tissues,  with  accompanying  fresh  intraperitoneal  hemorrhage 
of  small  or  large  amount.  More  exudate  is  then  thrown  out  about  the  new 
blood  mass,  lessening  the  danger  for  a  time.     This  process  may  be  repeated 


PATHOLOGY 


767 


many  times  witliin  the  course  of  a  few  months,  provided  the  patient  does 
not  in  the  meantime  succumb  to  hemorrhage  or  peritonitis.  Thus  there  is 
found  in  this  chiss  of  cases  a  gradually  increasing  mass  (Fig.  663),  accom- 
panied by  freciuent  attacks  of  pelvic  pain  and  marked  soreness.  This  class 
includes  the  majority  of  cases  of  extrauterine  pregnancy  that  come  to  opera- 
tion. Whether  or  not  the  patient's  color  and  pulse  are  much  atfected  depends 
upon  the  severity  of  the  hemorrhages.     In  many  cases  the  recurring  pain  and 


Fig.  662.     Pelvic  Hematocele.     Indicating  the  condition  where  there  has  been  a  tubal  abortion  and  the 
blood  from  it  has  gra\itated  to  the  cul-de-sac  and  become  surrounded  by  exudate. 


soreness  are  the  most  evident  features,  and  at  the  bedside  such  eases  are 
often  mistaken  for  ordinary  pelvic  inflammation. 

4.  Intraperitoneal  Rupture  with  Profuse  Hemorrhage.  There  is  a  free 
rupture  of  the  tube  (Fig.  664),  and  blood  pours  out  into  the  peritoneal- 
cavity  rapidly  and  in  great  quantity.  It  extends  among  the  intestines  and  in 
some  cases  practically  fills  the  abdominal  cavity,  as  indicated  in  Fig.  665. 
The  patient  at  once  passes  into  a  condition  of  severe  shock.  She  is  blanched, 
almost  pulseless  and,  with  the  air-hunger  and  extreme  pain,  presents  a  most 


768 


EXTRA-UTERINE  PREGNANCY 


distressing  picture.  The  cases  of  this  class  have  been  fittingly  designated 
as  the  "tragic"  cases.  This  severe  and  persistent  hemorrhage  is  most  likely 
to  occur  when  the  developing  ovum  is  situated  near  the  uterus,  in  that 
portion  of  the  tube  kno^\T2  as  the  "isthmus."  In  the  vast  majority  of  cases 
the  bleeding  ceases  when  the  patient  passes  into  complete  shock,  which  is 
nature's  provision  for  checking  the  hemorrhage.  In  exceptional  eases,  how- 
ever, the  patient  does  actually  bleed  to  death,  either  from  the  first  free  flow 


Fig.  663.  Blood  Mass  about  Tube.  Indicating  the  condition  where  there  has  been  rupture  of  the  tube, 
with  repeated  slight  hemorrhages,  resulting  in  a  large  mass  of  blood  and  exudate,  which  surrounds  the  tube. 

or  from  a  renewal  of  the  bleeding  due  to  vomiting,  l)Owel  movement,  sitting 
up  or  otlicr  disturbance  of  tlie  newly  formed  clot. 

5.  Tubal  Abortion.  If  the  place  of  lodgment  of  the  fertilized  ovum  happens  to 
be  near  the  outer  end  of  the  tube  (Fig.  661),  the  resulting  enlargement  of  the 
lumen  of  the  tube  by  the  developing  eml)ryo  opens  the  ends  of  the  tube,  and 
the  embryo  with  its  membranes  is  likely  to  be  extruded  from  the  end  of 
the  tube  into  the  peritoneal  cavity.  This  is  called  "tubal  abortion"  (Figs. 
666,  667).  Tubal  abortion  is  accompanied  Avith  more  or  less  intraperitoneal 
bleeding  and  gives  rise  to  practically  the  same  symptoms  as  tubal  rupture, 


PATHOLOGY 


769 


except  not  usually  so  severe.  A  considerable  proportion  of  cases  of  supposed 
tubal  rupture  are  really  eases  of  tubal  abortion,  particularly  those  resulting 
in  pelvic  liematocole  or  a  sliglit  mass  higher  about  the  tube. 

6.  Rupture  Into  Broad-Ligament.     When  tlie  break  in  the  tube  wall  takes 


Fig.  66-1.     Tubal  Pregnancy,  with  Rupture  into  the  Peritoneal  Ca\ity.     (Gilliam — Practical  Gynecology.) 


Fig.  665.     Tubal  Pregnancy  with  Intra-peritoneal  Rupture,  showing  the  blood  in  the  peritoneal  ca\-it.y 
among  the  intestinal  coils.     (Dickinson — American  Text-book  of  Obstetrics.) 

place  between  the  layers  of  the  broad-ligament,  the  hemorrhage  is  into  the 
connective  tissue  of  the  pelvis — forming  a  "hematoma,"  as  shown  in  Fig.  668. 
The  hemorrhage  may  be  moderate,  forming  a  hematoma  in  one  broad-ligament, 
or  it  may  be  severe,  forming  a  hematoma  which  gradually  extends  until  it 
fills  most  of  the  connective  tissue  space  in  one  or  both  sides  of  the  pelvis.    If 


770 


EXTRA-UTERINE  PREGNANCY 


the  extruded  embryo  coutinues  to  grow  in  the  broad-ligament,  then  arises 
the  condition  designated  as  "broad-ligament  pregnancy." 

7.  Interstitial  Pregnancy.    Ti'hen  the  ovum  lodges  and  develops  in  the  inter- 


Fig.  666.  Tubal  Pregnancy,  \sith  abortion 
through  the  abdominal  end  of  the  tube  into  the 
peritoneal  ca%ity.  The  end  of  the  tube  is  dilated, 
but  the  structures  have  not  yet  been  extruded. 
(Kelly — Operative  Gynecology.) 


Fig.  667.  The  Clots,  ^Membranes  and  Embryo  ex- 
truded into  the  peritoneal  ca^ity  in  the  case  of  Tubal 
Abortion  shown  in  Fig.  666.  (Kelly — Operative  Gyne- 
cology.) 


stitial  portion  of  the  tube  (Fig.  661  j,  the  resulting  condition  is  known  as 
"interstitial  pregnancy."  This  is  peculiar  in  that  the  development  takes 
place  "udthin  the  wall  of  the  uterus,  though  outside  the  uterine  cavitj^   (see 


Fig.  668.     Hematoma.     In  the  left  broad  ligament  is  indicated  a  small  hematoma  from  rupture  of  the  tube 
In  the  right  broad  ligament  is  indicated  a  much  larger  hematoma. 


PATHOLOGY 


771 


Fig.  371).  In  this  form  of  tul)al  pregnancy,  rupture  of  the  gestation  sac 
usually  does  not  take  place  until  much  later  than  with  the  ordinary  form. 
Also,  the  rupture  may  in  some  cases  be  into  the  uterine  cavity.  Consequently 
there  is  a  possibility  of  this  form  of  tubal  pregnancy  terminating  as  a  normal 
(intra-uterine)  pregnancy.  Interstitial  pregnancy  in  the  early  stages  ap- 
proaches in  symptoms  and  signs  very  close  to  normal  pregnancy,  and  hence 
presents  more  difficulties  in  diagnosis  than  a  pregnancy  farther  out  in  the 
tube.  It  is  difficult  and  sometimes  impossible  before  operation  to  distinguish 
between  interstitial  pregnancy  and  pregnancy  in  a  rudimentary  horn  of  the 
uterus  (cornual  pregnancy).  The  latter  is  an  intra-uterine  pregnancy  in  an 
abnormally  shaped. uterus  and  does  not  belong  to  the  affection  now  under 
consideration  (extra-uterine  pregnancy),  though  it  may  require  the  same 
operative  treatment,  as,  for  example,  in  the  case  shown  in  Fig.  409. 


Fig.  669.     Mother  and  Child  in  a  case  of  Extrauterine  Pregnancy,  operated  on  at  full  term.     (Cragin — 
American  Gynecological  and  Obstetrical  Journal.) 


8.  Ovarian  Pregnancy.  If  the  developing  ovum  is  found  "vvithin  the  ovary, 
it  constitutes  ''ovarian  pregnancy,"  of  wiiicli  a  few  well-substantiated  cases 
have  been  reported. 

9.  Wandering  Pregnancy.  If  the  pregnancy  is  found  in  the  peritoneal 
cavity  without  any  apparent  connection  with  the  tubes,  or  uterus,  or  ovary, 
it  is  called  a  "wandering  pregnancy,"  after  the  manner  of  designating 
fibroids  which  have  lost  their  connection  Avith  the  uterus.  Such  a  pregnant 
mass  (fetus  and  surrounding  membranes)  may  be  attached  to  and  receive 
blood  supply  from  various  structures.  In  an  interesting  case  reported  by 
Tuholske  the  placenta  was  attached  to  the  liver,  creating  a  most  serious 
condition.  "Abdominal  pregnancy"  is  a  general  term  which  has  been  used 
to  designate  cases  of  pregnancy  developing  in  the  peritoneal  cavity,  with  or 
without  connection  with  the  tube  or  ovary. 


772  EXTRA-UTERINE  PREGNANCY 

10.  Extrauterine  Pregnancy  Carried  to  Near  Term.  The  fetus  may  develop 
to  term  or  nearly  so.  The  embryo  and  membranes  remain  attached  to  the 
tube  and  derive  nourishment  there,  and  the  fetus  develops  in  the  peritoneal 
cavity  almost  the  same  as  in  the  uterus.  Again,  the  embryo  and  membranes 
may  be  extruded  entirely  from  the  tube  and  find  attachment  to  some  adjacent 
structure,  from  which  nourishment  is  derived,  or  to  some  distant  structure — 
for  example,  the  liver,  as  in  the  case  above  mentioned.  Tuholske  reported  a 
most  interesting  case  in  which  the  placenta  was  attached  to  the  liver.  In  this 
class  of  cases,  if  the  patient  survives  long  enough  and  the  fetus  continues  to 
grow  to  term,  false  labor  pains  come  on  and  the  child  dies,  and  it  then  consti- 
tutes a  foreign  body  in  the  abdomen  (Fig.  422).  This  may  lead  to  peritonitis 
and  death  of  the  mother,  or  the  dead  child  may  become  somewhat  encapsulated 
and  remain  for  months  or  years,  constituting  a  "lithopedion"  (Figs.  423  and 
424  show  such  a  case).  In  rare  instances  of  extra-uterine  pregnancy  carried 
to  near  term  the  child  has  been  saved  alive  by  operation.  Fig.  669  shows  the 
child  and  the  mother  in  one  such  case. 

SYMPTOMS   AND   DIAGNOSIS. 

Before  Rupture.  The  first  rupture  of  the  tube  with  slight  bleeding  takes 
place  within  a  few  weeks  after  the  lodgment  of  the  fertilized  ovum.  Previ- 
ous to  this  primary  rupture  the  symptoms  are  practically  those  of  an  early 
pregnancy.  The  patient  goes  over  her  menstrual  time  without  the  menstrual 
flow  appearing.  There  is  some  nausea,  usually  most  marked  in  the  morn- 
ing, and  perhaps  some  tenderness  of  the  breasts.  Pain  is  not  necessarily 
present.  There  may  be  some  soreness  in  the  pelvis,  either  general  or  localized 
to  one  side,  but  this  is  rarely  troublesome  enough  to  arouse  suspicion  of  any- 
thing abnormal,  for  some  soreness  through  the  pelvis  is  very  common  in 
normal  pregnancy  owing  to  the  marked  congestion  and  the  enlarging  uterus. 

Pelvic  examination  at  this  stage  shows  some  tenderness  about  the  adnexa 
of  one  side,  and  perhaps  a  small  mass,  due  to  the  enlargement  in  the  tube. 
However,  the  normal  ovaries  are  usually  tender,  especially  when  congested, 
as  in  early  pregnancy,  and  the  tenderness  is  frequently  more  marked  on  one 
side.  The  small  mass  in  the  tubal  region  is  really  the  only  positive  evidence 
of  any  abnormal  condition  within  the  pelvis,  and  as  far  as  known  this  mass  may 
have  been  there  for  a  long  time,  due  to  some  previous  trouble.  Unless  a 
previous  examination  has  shown  the  pelvis  to  be  clear,  making  it  certain 
that  the  little  mass  is  of  recent  development,  the  diagnosis  of  tubal  pregnancy 
is  hardly  justified,  for  there  is  not  sufficient  evidence  to  establish  it.  A  diag- 
nosis based  upon  such  insufficient  evidence  will  prove  erroneous  in  the  great 
majority  of  cases,  as  has  been  amply  demonstrated  by  the  operative  results 
from  such  hasty  diagnoses.  In  exceptional  eases  the  soreness  will  be  so 
well  localized  to  one  side  and  so  marked,  particularly  on  exertion,  and  the 
tenderness  of  the  little  mass  so  very  pronounced  on  palpation,  in  a  patient 
previously  perfectly  well,  that  a  diagnosis  of  tubal  pregnancy  with  operation 
for  the  same  before  rupture  may  be  safely  made.     But  such  cases  are  very 


SYMPTOMS  AND  DIAGNOSIS  773 

rare,  the  conditions  so  closely  simulating  normal  pregnancy  that  no  suspicion 
of  abnormality  is  aroused,  or,  it'  aroused,  tlie  examination  signs  are  not 
positive.  I  am  satisfied  that  a  large  proportion  of  the  cases  set  forth  as 
diagnosed  and  operated  on  "before  rupture"  are  really  not  seen  until  after 
the  primary  rupture.  There  may  not  be  much  disturbance  from  this  first 
rupture,  only  a  very  sliglit  hemorrhage  taking  place.  But  this  is  sufficient 
to  give  the  few  sharp  pains,  and  the  persistent  soreness,  and  the  markedly 
tender  mass  without  apparent  cause — the  three  symptoms  that  occupy  such 
an  important  place  in  the  diagnosis  of  tubal  pregnancy  after  rupture. 

Be  careful  (1)  to  make  a  pelvic  examination  in  every  case  of  early  preg- 
nancy in  which  there  is  sufficient  pain  or  soreness  in  the  pelvis  to  arouse 
suspicion  of  some  abnormality,  (2)  to  make  no  positive  diagnosis  of  tubal 
pregnancy  unless  the  physical  signs  justify  it,  and  (3)  to  pronounce  no  case 
"before  rupture"  which  shows  blood  in  the  pelvis,  or  recent  plastic  exudate 
and  adhesions  about  the  tube,  or  damage  to  the  peritoneal  coat  of  the  tube 
at  the  time  of  operation. 

Rupture  with  Repeated  Moderate  Hemorrhages.  In  the  majority  of  cases 
tubal  pregnancy  after  the  primary  rupture  presents  the  symptoms  and  signs 
of  ordinary  acute  or  subacute  pelvic  inflammation  (salpingitis),  but  with 
certain  peculiarities. 

Suppose  that  you  are  called  to  see  a  patient  with  pain  in  the  pelvis  and 
lower  abdomen,  and  a  tender  mass  beside  the  uterus  or  behind  it.  Is  the 
trouble  ordinary  pelvic  inflammation  or  is  it  tubal  pregnancy  with  resulting 
inflammation  ? 

As  ordinary  pelvic  inflammation,  in  the  form  of  salpingitis,  is  the  more 
common  affection,  it  is  to  be  assumed  that  the  trouble  is  ordinary  pelvic  in- 
flammation and  not  tubal  pregnancy,  unless  there  are  special  symptoms  point- 
ing to  the  latter.  The  special  symptoms  pointing  to  tubal  pregnancy  (but  not 
pathognomonic  of  it)  are  as  follows: 

1.  A  Missed  Menstruation.  The  patient,  previously  regular  in  her  menstrua- 
tion, fails  to  come  unwell  at  the  proper  time.  She  goes  overtime  a  few  days 
or  a  week,  or  several  weeks. 

2.  Sudden  Onset  of  Pain.  After  going  overtime  for  a  few  days  or  a  few 
weeks,  the  patient  is  suddenly  seized  with  pain  in  the  pelvis,  usually  severe 
enough  to  confine  her  to  bed,  and  in  exceptional  cases  she  is  completely 
prostrated  and  in  collapse. 

3.  Bloody  Vaginal  Discharge.  Usually  within  a  few  days  of  the  onset  oi 
the  pain  a  blood-stained  vaginal  discharge  appears.  The  patient  regards 
this  as  the  return  of  the  menstrual  flow.  But  generally  it  is  not  so  free  as  the 
regular  menstrual  flow,  and  does  not  stop  in  a  few  days  as  the  menstrual  flow 
should,  but  persists  as  an  irregular  bloody  discharge  for  a  week  or  two — some 
days  present  and  other  days  absent.  In  some  cases  there  are  shreds  of  mem- 
brane and  blood-clots  in  the  discharge,  leading  to  the  supposition  that  a 
miscarriage  has  taken  place. 

4.  Only  Slight  Fever.     The  temperature  may  go  up  to  102°  or  even  higher 


774  EXTRA-UTERINE  PREGNANCY 

at  the  onset  of  tlie  trouble,  but  after  that  it  usually  ranges  about  100°  and 
may  go  to  normal.  The  absence  of  marked  fever  is  one  of  the  strong  points 
in  distinguishing  tubal  pregnancy  from  early  abortion,  -with  persistent  bloody 
discharge  and  infection  and  salpingitis. 

5.  Evidence  of  Internal  Hemorrtiag'e.  This  Trill,  of  course,  vary  with  the 
amount  of  blood  lost  internally.  If  the  internal  hemorrhage  is  free,  the 
patient  may  be  in  collapse  within  a  few  minutes  after  the  onset  of  the  pain. 
In  other  cases  the  internal  bleeding  is  so  slight  as  to  produce  no  effect  on  the 
patient's  pulse  or  color — but  it  causes  pain. 

6.  Exacerbations  of  Pain  without  Apparent  Cause  and  without  Decided 
Elevation  of  Temperature.  This  is  characteristic  of  those  cases  of  tubal  preg- 
nancy in  which  there  are  repeated  slight  internal  hemorrhages. 

In  salpingitis,  with  the  patient  c^uiet  in  bed,  such  exacerbations  of  pain 
could  be  caused  only  by  an  increase  in  the  inflammatory  process,  and  this 
would  be  accompanied  by  a  decided  rise  in  temperature. 

7.  Signs  of  Pregnancy.  Some  of  the  early  signs  of  pregnancy  may  be 
present — for  example,  stomach  disturbance,  or  pain  in  the  breasts,  or  softening 
of  the  cervix  uteri. 

8.  Absence  of  Intrauterine  Pregnancy.  It  may  be  very  difficult  to  deter- 
mine, in  a  given  case,  whether  the  trouble  is  tubal  pregnancy  with  slight 
hemorrhage,  or  an  incomplete  abortion  with  persistent  bleeding  and  mild 
sepsis  and  salpingitis.  In  such  a  doubtful  case  the  uterus  may  be  cleared 
out  with  the  curet  and  the  scrapings  examined.  If  there  has  been  recent 
pregnancy  within  the  uterus,  the  microscopic  examination  of  the  tissues 
removed  will  show  chorionic  villi.  If  the  trouble  is  tubal  pregnancy,  there 
will  be  no  fetal  structures  in  the  scrapings. 

This  procedure  is  somewhat  dangerous,  for,  if  tubal  pregnancy  be  present, 
a  fresh  hemorrhage  and  a  serious  one  may  be  started  by  the  manipulations. 
Consequently,  curetment  should  be  employed  in  these  doubtful  cases  only 
when  serious  symptoms  make  a  positive  diagnosis  necessary  at  once.  In  such 
a  case  the  operator  should  have  arrangements  made  so  that  immediate 
abdominal  section  may  be  carried  out  should  threatening  symptoms  indicating 
internal  hemorrhage  arise  during  the  process  of  curetment. 

Usually  in  tubal  pregnancy  the  internal  hemorrhage  is  not  severe  at  first, 
and  there  may  be  a  number  of  these  slight  hemorrhages  at  intervals  of  a  few 
days  or  a  few  weeks.  The  hemorrhages  are  not  severe  enough  to  affect  the 
patient's  pulse  appreciably.  They  cause  only  pain  and  the  evidences  of  peMc 
inflammation.  The  symptoms  and  diagnosis  in  this  class  of  cases  are  well 
shoA^Ti  by  the  follo"wing  typical  case : 

Patient  thirty-se ,  v^n  years  of  age.  General  health  good,  riau  one  child  seven  years 
ago.  No  pregnancy  since.  Never  had  any  uterine  or  pelvic  trouble.  Menstruation  was 
regular,  every  twenty-seven  days,  until  about  two  months  before  I  saw  her.  The  last 
regular  menstruation  occurred  December  3.  The  flow  was  in  every  way  normal  and  at 
the  right  time.  December  .30  was  the  time  for  the  next  flow  to  appear,  but  it  was 
missed  entirely.  The  patient  felt  well  and  there  was  no  reason  why  the  menses  should 
stop,  aside  from  pregnancy.    There  was  some  nausea,  the  breasts  began  to  enlarge 


SYMPTOMS  AND  DIAGNOSIS  775 

and  were  somewhat  painful,  and  the  patient  supposed  herself  pregnant.  She  felt  well 
up  to  January  26.  That  was  the  day  for  her  menses  to  appear,  supposing  she  had  not 
missed.  The  previous  day  she  had  been  doing  extra  work,  but  slept  well.  In  the  morn- 
ing she  arose  and  went  about  her  usual  household  duties,  feeling  well.  About  8  a.  m., 
while  still  engaged  with  her  light  work,  she  was  seized  with  a  sudden  severe  pain 
in  the  pelvis.  The  pain  was  intense.  She  managed  to  get  to  the  bed  and  threw  her- 
self across  the  foot  of  it.  Her  physician  was  called  and  found  it  necessary  to  give 
morphine  and  to  repeat  it.  This,  of  course,  relieved  her  very  much,  but  still  the  least 
change  of  position  increased  the  pain  and  not  until  evening  could  she  be  moved 
enough  to  remove  her  dress  and  arrange  her  in  bed.  Her  temperature  as  then  102°. 
In  questioning  her  later,  I  could  get  no  history  of  shock.  The  patient  did  not  remem- 
ber having  felt  particularly  weak  or  faint  or  nauseated — she  noticed  only  the  severe 
pain. 

Morphine  and  other  preparations  of  opium  were  continued  in  small  doses  occa- 
sionally for  several  days. .  Hot  stupes  were  applied  to  the  lower  abdomen  and  frequent 
doses  of  salts  were  given  to  relieve  the  constipation.  The  pain  and  soreness  gradually 
became  less.  The  temperature  varied  from  101°  to  99°.  On  the  third  day  a  bloody 
vaginal  discharge  appeared.  This  was  not  like  the  menstrual  flow,  but  was  scanty 
and  irregular.  It  continued  a  few  days  and  then  stopped.  There  were  no  membranes 
or  large  clots  noticed.  In  about  a  week  the  patient  was  feeling  so  much  better  that 
she  sat  up  for  an  hour  or  two.  The  pain  then  reappeared  and  she  was  obliged  to 
return  to  bed.  More  or  less  pain  and  soreness  through  the  pelvis  continued,  and  this 
time  she  remained  in  bed  ten  days.  There  was  more  vaginal  discharge,  but  it  was 
not  profuse  nor  irritating.  It  was  occasionally  streaked  with  blood.  After  ten  days 
in  bed  she  felt  so  well  that  she  sat  up  in  a  chair  fcr  a  short  time.  No  disturbance  fol- 
lowing this,  she  sat  up  the  next  day  a  little  longer.  After  five  days  she  walked  out 
to  the  dining  room  and  helped  about  the  table.  She  had  then  been  free  from  pain  for 
several  days.  The  next  day,  however,  the  pain  returned.  It  was  not  severe,  but  she 
remained  in  bed.  The  following  morning  the  pain  was  worse,  and  I  was  then  called 
in  consultation — about  three  weeks  after  the  beginning  of  the  attack.  I  found  the 
patient  confined  to  her  bed  with  pelvic  pain  and  decided  tenderness  over  all  the  lower 
abdomen.    Good  pulse,  good  color,  temperature  99°. 

On  vaginal  and  bimanual  examination  I  found  marked  tenderness  all  about  the 
uterus.  In  the  right  tubal  region  there  was  a  small  hard  mass  about  the  size  of  the 
ovary,  but  much  harder  and  not  movable.  In  the  left  tubal  region  there  was  a  larger, 
softer  mass,  which  apparently  occupied  nearly  all  the  left  side  of  the  pelvis.  It  was 
so  soft  that  the  borders  were  not  distinct.  Both  masses  were  situated  rather  high, 
but  there  was  so  much  tenderness  that  I  could  not  press  into  the  pelvis  deep  enough 
to  satisfactorily  outline  them.  There  was  apparently  no  exudate  in  the  cul-de-sac  of 
Douglas.    There  was  a  slight  vaginal  discharge  streaked  with  blood. 

Taking  into  consideration  the  history  of  the  case  and  the  findings  on  examination, 
I  made  a  diagnosis  of  tubal  pregnancy,  with  rupture  three  weeks  previously  and  re- 
peated slight  hemorrhages  since.  I  could  not  tell  which  tube  the  pregnancy  was  in, 
for  there  was  a  tender  mass  on  each  side  of  the  uterus,  so  I  would  not  venture  a 
diagnosis  in  that  respect.  However,  I  was  inclined  to  think  that  the  pregnancy  was 
situated  in  the  right  side,  as  that  mass  was  the  firmer  and  its  outlines  more  distinct. 

I  advised  that  the  patient  be  brought  to  the  city  at  once  for  operation.  You  may 
think  that  rather  risky  advice  for  a  case  of  ruptured  extra-uterine  pregnancy.  But 
I  was  satisfied  that  the  focus  of  disturbance  was  well  surrounded  by  plastic  exudate, 
and  that  a  trip  on  the  train  with  the  patient  flat  on  the  stretcher  all  the  time  would 
not  be  attended  with  much  risk,  particularly  in  view  of  the  fact  that  she  had  already 
been  up  and  walking  about.  I  had  gone  to  the  town  prepared,  of  course,  to  do  what- 
ever was  necessary  at  the  house,  but  I  concluded  that  the  increased  safety  of  the 
operation  in  a  hospital  outweighed  the  danger  of  the  trip.    The  trip  to  the  hospital 


776  EXTRA-UTERINE  PREGNANCY 

caused  no  particular  disturbance.  When  I  opened  the  abdomen  I  found  blood-clots 
and  adhesions  about  the  left  tube.  The  outer  part  of  the  tube  was  enlarged  to  the 
size  of  a  lemon  and  contained  the  fetus  and  membranes  still  attached.  The  situation 
of  the  mass  of  blood  clots  and  exudate  was  rather  unusual.  It  was  principally  in 
front  of  the  uterus,  over  the  bladder.  The  small  mass  in  the  right  side  had  no  con- 
nection with  the  tubal  pregnancy.  It  was  the  right  ovary  surrounded  and  bound  down 
by  adhesions.  After  the  left  tube  and  ovary  had  been  removed  and  the  mass  of  blood- 
clots  cleared  out,  the  right  ovary  was  freed  from  its  adhesions  and  left  in  place.  The 
patient  recovered  without  incident.* 

In  this  case  there  was  no  evidence  of  sudden  profuse  loss  of  blood,  and 
from  my  observations  I  am  inclined  to  the  opinion  that  this  holds  good  in  a 
large  majority  of  cases  of  extra-uterine  pregnancy. 

Rupture  with  Profuse  Hemorrhage.  In  exceptional  cases  there  is  a  sudden 
loss  of  a  large  amount  of  blood  into  the  peritoneal  cavity.  In  such  a  case 
the  symptoms  are  striking  and  urgent.  The  patient's  face  is  blanched,  her 
nose  and  forehead  and  fingers  are  cold,  the  pulse  is  rapid  and  weak  and  fail- 
ing, a  cold  sweat  appears  on  the  face,  respiration  is  short  and  labored — and 
over  all  is  the  intense  pain,  which  is  due  to  the  blood  spreading  through  the 
peritoneal  cavity,  and  of  which  the  patient  complains  as  long  as  she  has 
sufficient  strength.  These  are  desperate  cases.  This  sudden  profuse  hemor- 
rhage may  appear  with  the  first  attack  of  pain,  or  the  first  hemorrhage  may  be 
slight,  the  severe  hemorrhage  taking  place  after  several  hours  or  several  days. 
The  following  case,  from  my  records,  gives  a  practical  idea  of  the  clinical 
features  of  the  cases  of  this  class : 

About  nine  o'clock  one  morning  I  was  called  by  telephone  to  see  a  woman  who, 
the  message  stated,  was  having  severe  pain  in  the  abdomen.  When  I  reached  the 
house  the  pain  had  diminished  considerably,  but  was  still  very  troublesome.  It  was 
diffuse  throughout  the  lower  abdomen  and  was  accompanied  by  marked  tendei'ness 
over  the  same  region.  The  abdominal  muscles  were  tense.  Movement  of  the  patient 
in  the  bed  or  jarring  of  the  bed  increased  the  pain.  Patient's  color  was  good.  Tempera- 
ture was  99°.  Pulse  was  76,  full  and  regular.  There  was  a  bloody  vaginal  discharge, 
which  had  appeared  the  day  before  and  which  the  patient  thought  was  her  menstrual 
flow  a  few  days  delayed. 

The  history  obtained  was  that  the  patient's  previous  health  had  been  good,  that 
menstruation  had  been  regular  (about  every  28  days)  and  painless.  Nothing  out  of  the 
ordinary  was  noticed  until  one  week  before.  It  was  then  her  time  to  come  unwell,  but 
the  flow  did  not  appear.  She  thought  nothing  of  this,  as  she  occasionally  went  a  few 
days  over  time.  She  felt  well  and  there  was  no  nausea  or  other  indication  of  preg- 
nancy. In  a  few  days  a  bloody  flow  appeared.  This  was  not  so  free  nor  so  dark  as 
the  regular  monthly  flow.  But  the  patient  supposed  it  to  be  the  menstrual  flow,  and 
she  continued  to  attend  to  her  household  duties  without  discomfort. 

The  morning  I  was  called  she  had  been  superintending  her  household  work  as  usual. 
While  standing  by  a  table  she  was  seized  with  severe  pain  in  the  lower  abdomen. 
She  was  lifted  to  a  chair  and  the  pain  became  less,  and  she  ate  breakfast.  In  an  hour 
the  pain  had  almost  disappeared  and  she  went  upstairs,  and  felt  very  comfortable 
while  sitting  reading.  She  felt  a  desire  to  go  to  stool  and  during  the  bowel  movement 
the  pain  returned  with  increased  severity,  so  that  she  had  to  be  helped  to  her  room. 


♦Report  of  Two  Cases  of  Pregnancy  Requiring  Operation,  by  H.  S.  Crossen,  M.  D.— St.  Louis  Medical  Re- 
view, August  24,  1901. 


DIFFERENTIAL   DIAGNOSIS  777 

When  I  sav/  the  patient,  about  an  hour  hiter,  she  was  in  good  general  condition,  as 
already  explained,  and  with  no  decided  symptoms  except  the  abdominal  tenderness 
and   pain   on   movement. 

Vaginal  examination  showed  the  uterus  slightly  enlarged  and  softened,  and  the 
whole  interior  of  the  pelvis  very  tender.  The  least  movement  of  the  uterus  caused 
pain.  The  pelvic  tenderness  was  so  marked  that  satisfactory  bimanual  examination 
was  not  possible.  No  mass  could  be  felt  to  either  side  of  the  uterus  nor  behind  it. 
The  cervix  was  closed.  The  marked  and  widespread  tenderness  In  the  pelvis  and 
lower  abdomen  showed  there  was  something  more  serious  than  a  simple  miscarriage, 
which  patient  had  concluded  was  the  trouble.  The  sudden  onset  of  intense  pain,  with 
complete  absence  of  previous  disturbance  and  without  fever,  excluded  peritonitis  due 
to  inflammation  of  the  tubes  or  appendix.  There  was  no  evidence  of  intestinal  obstruc- 
tion, or  volvulus,  or  intussusception.  The  pain  and  hyperesthesia  were  not  due  to  any 
drug  habit,  for  the  patient  had  no  such  habit.  The  diagnosis  of  extra-uterine  pregnancy 
was  fairly  clear,  in  spite  of  the  fact  that  no  pelvic  mass  could  be  located.  I  wished  to 
get  the  patient  to  the  hospital  before  operating,  and,  as  the  first  hemorrhage  had  evi- 
dently been  slight,  I  though  that  by  keeping  her  perfectly  quiet  for  a  day  or  two  she 
could  be  safely  moved.    I  gave  orders  accordingly. 

The  spontaneous  pain  in  the  lower  abdomen  subsided  and  the  tenderness  gradually 
diminished.  By  evening  the  patient  was  comfortable  when  perfectly  quiet.  The  next 
morning  the  patient  was  much  improved  and  was  feeling  comfortable — so  comfortable 
that  she  did  not  consider  herself  very  sick,  and  did  not  take  kindly  to  the  injunction  to 
lie  quiet  in  the  bed  and  on  no  account  to  raise  up.  That  afternoon  the  pain  returned 
to  some  extent,  but  it  was  not  severe,  and  I  saw  nothing  to  indicate  that  the  patient 
would  not  be  in  good  condition  the  next  morning  for  the  trip  to  the  hospital,  where 
a  room  had  already  been  engaged  for  her.  But  near  midnight  I  received  a  message 
that  the  severe  pain  had  returned  and  that  the  patient  was  short  of  breath.  Hurrying 
to  the  house,  I  found  the  patient  in  collapse.  The  pulse  was  small  and  rapid,  the  fea- 
tures were  blanched  and  pinched — the  greatest  possible  contrast  to  the  rosy,  robust 
appearance  which  she  presented  a  few  hours  before.  The  extremities  were  cold,  and 
a  cold  perspiration  stood  out  on  the  face.  Dyspnoea  was  present,  but  the  patient  com- 
plained only  of  the  intense  abdominal  pain,  which  seemed  to  be  increasing.  The 
hemorrhage  was  still  going  on,  as  evidenced  by  the  increasing  widespread  pain  and 
the  continued  failing  of  the  pulse.  By  the  time  the  hasty  preparations  for  the  neces- 
sary operation  were  completed,  the  pulse  was  thready  and  at  times  scarcely  per- 
ceptible. The  patient  told  me  afterwards  that  she  believed  she  was  dying,  as  she 
could  feel  the  chill  on  the  extremities  creeping  closer  and  closer  towards  the  trunk. 

When  preparations  were  completed,  the  patient  was  etherized  and  the  abdomen 
opened.  The  peritoneal  cavity  was  full  of  blood.  The  ruptured  tube  was  quickly 
located  by  touch  and  clamped.  That  stopped  the  bleeding  temporarily.  The  principal 
part  of  the  blood  was  then  cleared  out  of  the  abdomen,  the  affected  adnexa  removed, 
the  peritoneal  cavity  flooded  with  hot  normal  saline  solution  and  the  abdomen  closed. 
The  patient  was  almost  pulseless  and  continued  in  that  condition  for  40  hours  in  spite 
of  all  stimulating  means.  Good  reaction  then  gradually  came  on  and  the  patient  im- 
proved rapidly  and  made  a  perfect  recovery.  Subsequently  she  informed  me  that  late 
in  the  afternoon  before  the  nearly-fatal  hemorrhage  she  was  feeling  so  well  that  she 
sat  up  in  bed  to  take  nourishment  and  to  chat  with  friends,  regarding  my  strict  admo- 
nition to  keep  perfectly  quiet  on  her  back  as  "overcautious." 

DIFFERENTIAL  DIAGNOSIS. 

This  subject  is  of  interest  to  every  one  called  to  make  a  diagnosis  in  acute 
abdominal  affections,  for  in  many  cases  diagnosticated  and  operated  on  as 
tubal  pregnancy  the  operation  revealed  that  the  trouble  was  not  tubal  preg- 


778  EXTRA-UTERINE   PREGNANCY 

nancy,  but  some  entirely  different  affection.  There  are  many  conditions 
that  may  simulate  one  or  more  of  the  principal  symptoms  of  extrauterine 
pregnancy,  and  these  must  be  taken  into  consideration  in  the  differential 
diagnosis. 

The  cardinal  symptoms  of  early  tubal  pregnancy  are  (1)  a  missed  menstrua- 
tion, (2)  sudden  onset  of  pain  (with  or  without  shock),  (3)  bloody  vaginal 
discharge,  (4)  a  tender  mass  beside  the  uterus,  (5)  only  slight  fever,  and 
(6)  exacerbations  of  the  pain  and  enlargement  of  the  mass  without  corre- 
sponding elevation  of  temperature.  In  atypical  cases  there  may  be  decided 
fever  or  onset  of  pains  mthout  missed  menstruation  or  other  variations  from 
the  rule.  Again,  the  internal  hemorrhage  may  be  very  severe  at  first,  requir- 
ing a  diagnosis  at  once  before  the  appearance  of  later  confirmatory  evidences. 
It  may  be  impossible  to  feel  a  mass,  for  the  liquid  blood  itself  gives  no  well- 
marked  resistance  and  yet  causes  so  much  tenderness  that  the  enlarged  tube 
can  not  be  satisfactorily  palpated.  Freshly  coagulated  blood  gives  a  boggi- 
ness,  but  not  a  distinctly  outlined  mass.  After  a  short  time  there  develops 
a  distinct  mass,  due  to  the  fibrin  and  adhesions  and  infiltration  associated 
with  the  blood  clot. 

The  difficulties  of  differentiation  are  due  largely  to  the  fact  that  many 
cases  of  extrauterine  pregnancy  are  atypical  in  symptomatology — ^present- 
ing some  of  the  prominent  symptoms,  but  lacking  others.  Now,  there  are 
other  affections  that  may  present  two  or  three  of  the  prominent  symptoms 
of  tubal  gestation,  and  if  the  distinguishing  characteristics  of  the  other 
affection  happen  to  be  absent  or  obscured  a  mistake  in  diagnosis  is  probable. 
Space  will  not  permit  consideration  of  all  the  conditions  that  may  simulate 
tubal  pregnancy;  only  a  few  of  the  more  common  ones  may  be  discussed. 
These  may  be  grouped  into  two  classes — first,  those  conditions  in  which  the 
principal  feature  is  a  tender  pelvic  mass,  associated  with  some  of  the  other 
symptoms  of  tubal  pregnancy,  and,  second,  those  conditions  in  which  the 
principal  feature  is  sudden  abdominal  pain  and  collapse  without  apparent 
cause — i.  e.,  without  the  disturbances  that  usually  precede  or  accompany  col- 
lapse from  other  diseases.  These  two  main  groups  may  be  further  divided 
into  sub-groups.  'My  object  here  is  to  put  the  reader  in  practical  touch  witl- 
the  more  common  conditions  that  may  simulate  tubal  pregnancy,  that  he  may 
be  on  guard  against  them  and  thus  avoid  mistakes.  The  most  satisfactory 
way  to  do  this  is  to  give  actual  examples — i.  e.,  to  describe  the  conditions 
present  in  cases  that  have  actually  simulated  tubal  pregnancy  so  closely 
that  they  were  mistaken  for  it.  In  each  of  the  following  cases  the  symptoms 
were  so  deceptive  that  they  caused  a  mistake  in  diagnosis.  There  is  space 
for  only  one  example  under  each  of  the  deceptive  conditions.  iMany  other 
examples,  with  references,  are  given  in  a  recent  article*  on  the  subject. 


♦Conditions  Simulating  Tubal  Pregnancy  by  H.  S.  Crossen,  M.  D.  Read  in  the  Section  on  Obstetrics  and 
Diseases  of  Women  of  the  American  Medical  Association,  at  the  Sixtieth  Annual  Session,  held  at  Atlantic  City, 
June,  1909.— /our.  Am.  Med.  Assn.,  Vol.  LIV,  p.  519. 


CONDITIONS  SIMULATING  TUBAL  PREGNANCY  779 

A  Tender  Pelvic  Mass  with  Other  Symptoms  of  Tubal  Pregnancy. 

Gonorrhoeal  Salpingitis.  Witli  no  other  disease  have  I  experienced  so  much 
difficulty  in  diffcrontiatiou  from  early  tul)al  pregnancy  as  with  salpingitis 
of  gonorrhoeal  origin.  Typical  cases  of  salpingitis  are,  of  course,  easily  dis- 
tinguished from  typical  cases  of  tubal  pregnancy.  The  difficulty  lies  in  the 
fact  that  either  may  be  atypical,  and  as  they  become  atypical  they  may 
approach  each  other  until  their  manifestations  are  practically  alike — that  is, 
gonorrhoeal  salpingitis  (atypical)  may  produce  the  symptoms  and  signs  of 
tubal  pregnancy  (slightly  atypical).  Such  cases  are  not  very  frequent,  but 
they  are  encountered  occasionally  in  the  examination  of  a  large  number  ot 
cases  of  supposed  extrauterine  pregnancy,  and  when  encountered  they  prove 
most  deceptive  and  misleading. 

Chronic  Gonorrhoeal  Salpingitis. — Patient,  aged  32,  referred  to  me  by  Dr.  J.  D. 
Beatty,  of  Troy,  Mo.  Last  normal  menstruation  August  10.  In  September  went  over 
time  ten  days.  Felt  as  well  as  usual  and  supposed  herself  pregnant.  No  stomach  dis- 
turbance or  breast  pains.  About  September  20  had  a  scanty  flow  for  two  days.  She  felt 
well  and  there  was  no  further  bloody  discharge  for  two  weeks,  when  it  started  again.  A 
day  later  she  was  seized  with  severe  pains  extending  all  through  the  lower  abdomen. 
No  shock,  just  pain,  at  times  cramp-like.  This  pain  continued  off  and  on  for  a  week. 
Patient  was  confined  to  bed  and  had  to  be  given  morphine.  A  physician  was  called  and 
made  a  diagnosis  of  abortion.  No  membrane  passed  and  there  was  only  one  small  clot. 
Patient  was  then  curetted,  but  not  much  was  obtained — apparently  only  some  thickened 
endometrium.  No  fetus  or  membranes  or  shreds  of  tissue  were  seen  at  any  time.  Pa- 
tient felt  better  after  the  curetment,  but  still  continued  sick,  confined  to  bed  with 
abdominal  pain  and  tenderness.  Temperature  99°  to  100°.  Twelve  days  later,  as  there 
was  no  material  improvement,  the  uterus  was  curetted  again,  but  without  result.  The 
trouble  continuing,  Dr.  Beatty  was  called  in  consultation.  The  abdominal  pains  and 
tenderness  continued  and  the  temperature  then  (after  the  second  curetment)  ranged 
from  100°  to  101°.  Six  days  after  the  second  curetment  the  patient  was  brought  to 
St.  Louis  and  placed  under  my  care. 

Examination. — This  showed  the  uterus  retrodisplaced  and  fixed,  and  blended  with  a 
tender  mass  of  adnexal  origin  extending  into  both  sides  of  the  pelvis.  The  average 
temperature  was  100°;  pulse,  98;  respiration,  20.  The  lowest  temperature  was  99.2° 
and  the  highest  100.6°. 

Diagnosis. — There  was  evidently  serious  adnexal  trouble  of  apparently  recent  origin, 
and  any  one  of  the  following  conditions  was  possible:  (1)  salpingitis  following  miscar- 
riage, (2)  an  acute  exacerbation  of  a  chronic  salpingitis,  and  (3)  tubal  pregnancy  with 
repeated  slight  hemorrhages.  Against  the  first  were  the  low  temperature  (much  lower 
than  consistent  with  an  acute  infection  of  sufficient  severity  to  cause  the  symptoms) 
and  the  absence  of  evidences  of  miscarriage.  Against  the  second  were  the  low  tem- 
perature with  acute  symptoms,  no  history  of  preceding  severe  symptoms  indicating 
old  suppuration  in  the  pelvis  (though  there  had  been  mild  pelvic  distress  for  some 
years)  and  the  association  of  the  trouble  with  missed  menstruation,  followed  by  sud- 
den onset  of  pain  and  the  appearance  of  an  irregular  bloody  vaginal  discharge.  If  due 
to  an  old  inflammatory  trouble,  one  would  expect  the  menstrual  flow  to  be  increased 
instead  of  missed,  and  the  pain  and  other  symptoms  to  be  of  rather  gradual  onset  and 
increasing  in  severity  as  fluctuation  appeared  in  the  mass.  In  favor  of  the  third  (tubal 
pregnancy)  were  missed  menstruation  followed  by  sudden  onset  of  pain,  irregular 
bloody  discharge,  absence  of  positive  evidence  of  a  miscarriage,  and  the  presence  of 
fluctuation  in  the  mass,  associated  with  low  temperature   (much  lower  than  was  con- 


730  EXTRA-UTERINE  PREGNANCY 

sistent  with  a  pocket  of  pus).  It  seemed  a  fairly  clear  case  of  tubal  pregnancy — one  of 
the  class  frequently  met,  in  which  there  is  no  great  loss  of  blood  at  one  time,  but  re- 
peated slight  hemorrhages  with  a  gradually  increasing  mass.  Accordingly  that  diag- 
nosis was  made. 

Operation. — On  opening  the  abdomen  no  tubal  pregnancy  was  found.  The  trouble 
was  chronic  adnexal  inflammation— there  being  a  tubo-ovarian  abscess  on  the  left  side, 
which  gave  the  fluctuation,  and  chronic  salpingitis  on  the  right  side,  the  remaining 
part  of  the  mass  being  formed  by  adhesions  and  exudate.  The  damaged  adnexa  and 
the  chronically  inflamed  appendix  were  removed  and  the  uterus  fastened  forward. 
The  patient  made  a  prompt  recovery  with  complete  relief. 

Careful  bacteriologic  investigation  of  the  removed  adnexa  showed  no  bacteria  of  any 
kind.  This  excluded  recent  infection.  The  case  was  evidently  one  in  which  there  was 
a  gonorrhoeal  infection  long  ago  (there  were  confirmatory  facts  in  the  history),  the 
development  of  pyosalpinx  with  only  slight  symptoms  of  a  mild  character,  the  death 
of  the  bacteria  (which  commonly  takes  place  in  gonorrhoeal  pyosalpinx),  and  the  per- 
sistence of  sterile  pus  in  a  sac  which  acted  as  an  irritating  foreign  body  in  the  pelvis. 
No  evidence  of  pregnancy  was  found.  Why  the  menstruation  was  missed  I  can  not 
say.  In  some  other  cases  of  gonorrhoeal  salpingitis  I  have  encountered  this  misleading 
symptom. 

Acute  Double  Salpingitis.— Patient,  aged  19,  referred  to  me  by  Dr.  George  F.  Chopin, 
of  St.  Louis.  About  two  weeks  after  marriage  she  failed  to  come  unwell  properly.  At 
the  menstrual  time  there  was  a  slight  bloody  discharge,  but  not  a  good  menstrual  flow. 
There  was  some  soreness  and  pain  in  the  pelvis.  After  this  had  continued  a  few  days 
she  was  seized  with  sudden  severe  pain  in  the  lower  abdomen,  accompanied  by  shock. 
With  the  weakness  and  faintness  and  pain  she  could  hardly  move,  even  to  turn  over 
in  bed,  for  several  hours.  The  severe  pain  gradually  subsided,  but  marked  soreness 
remained,  so  much  so  that  the  patient  was  obliged  to  lie  very  quiet.  A  physician  who 
was  called  examined  the  patient  and  said  that  she  was  having  a  miscarriage.  A  par- 
tial curetment  was  carried  out,  but  only  a  small  amount  of  blood  was  removed.  No 
fetus,  membranes  or  large  clot  was  passed  at  any  time.  The  patient  and  her  husband 
then  became  uneasy  at  the  apparent  seriousness  of  the  trouble  and  the  day  after  the 
curetment  called  Dr.  Chopin,  who  asked  me  to  see  the  patient. 

Examination. — The  patient  was  confined  to  bed  with  pain  in  the  lower  abdomen  and 
a  bloody  vaginal  discharge.  There  was  marked  tenderness  on  abdominal  and  bimanual 
examination,  and  there  was  a  boggy  induration  on  each  side  of  the  uterus  with  marked 
tenderness.  No  membranes  or  shreds  were  found  in  the  cervix  or  in  the  bloody  dis- 
charge. The  discharge  was  blood  and  mucus,  without  noticeable  pus  admixture.  The 
trouble  seemed  to  be  around  the  uterus  rather  than  in  it.  The  temperature  was  low, 
fluctuating  between  100°  and  101°.  Here  was  a  patient,  apparently  previously  healthy, 
seized  with  a  severe  abdominal  pain  and  decided  shock,  associated  with  imperfect 
menstruation,  an  irregular  bloody  discharge,  a  tender  mass  partially  surrounding  the 
uterus,  and  low  temperature.  I  made  a  tentative  diagnosis  of  tubal  pregnancy  with 
some  internal  hemorrhage,  but,  not  being  entirely  satisfied,  I  concluded  to  watch  the 
case  for  a  while. 

Under  mild  sedatives  and  strict  confinement  to  bed  the  patient  became  very  com- 
fortable. The  temperature  ran  about  100°.  After  a  few  days  she  felt  so  much  better 
that,  without  my  permission,  she  began  to  go  to  the  washstand.  On  one  of  these  trips 
across  the  room  she  was  seized  with  pain  and  almost  fainted  before  she  could  reach 
the  bed.  There  was  then  more  pain  and  pelvic  soreness  and  an  increase  in  the  tender 
mass  about  the  uterus.  I  then  insisted  on  the  patient's  removal  to  the  hospital,  where 
she  was  kept  under  observation  for  five  days  longer.  On  admission  the  temperature 
was  101.2°;  pulse,  100;  respiration,  24.  There  was  considerable  abdominal  pain,  re- 
quiring a  sedative  occasionally.  The  next  day  the  temperature  was  99°  and  for  four 
days  did  not  go  above  99.6°.   In  the  meantime  the  patient  felt  comfortable,  could  sleep 


CONDITIONS  SIMULATING  TUBAL   PREGNANCY  781 

well,  her  appetite  returned,  and  the  pelvic  soreness  diminished.  The  bloody  discharge 
continued.  The  fifth  day,  without  apparent  cause,  the  abdominal  pain  returned  and 
became  very  severe.  The  pulse  rose  to  132;  temperature,  100.6°;  respiration,  24.  On 
examination  the  tender  pelvic  mass  was  found  to  be  larger.  The  tentative  diagnosis 
of  tubal  pregnancy  seemed  confirmed  by  the  spontaneous  recurrence  of  severe  pain, 
the  rapid  pulse,  and  the  continued  enlargement  of  the  pelvic  mass  with  low  tempera- 
ture. 

Operation. — When  I  opened  the  abdomen  I  found  there  was  no  extrauterine  preg- 
nancy, but  instead  an  acute  double  salpingitis,  with  leakage  of  pus  into  the  peritoneal 
cavity  and  the  formation  of  extensive  adhesions.  The  tubes  were  so  badly  damaged  that 
I  thought  best  to  excise  them.  After  establishing  free  drainage  of  the  infected  area,  I 
explored  the  interior  of  the  uterus,  thinking  that  possibly  there  had  been  a  miscarriage 
after  all,  with  infection  following  it;    but-  no  evidence  of  pregnancy  was  found. 

The  patient  recovered  without  particular  incident. 

Examination  of  the  pus  from  the  tubes  showed  gonococci  in  abundance  and  in  pure 
cultures.  The  case  was  one  of  gonorrhoeal  infection  following  marriage,  the  Infection 
affecting  the  vagina  but  slightly  and  passing  rapidly  up  into  the  uterus  and  tubes  and 
out  into  the  peritoneal  cavity.  A  striking  fact,  and  perhaps  the  most  misleading  one 
in  this  particular  case,  was  the  absence  of  the  usual  evidences  of  acute  gonorrhoeal 
vaginitis  (burning  on  urination,  vaginal  tenderness,  and  free  purulent  discharge). 
These  were  so  slightly  marked  that  there  was  no  suggestion  of  the  trouble  being  acute 
gonorrhoea.  The  purulent  character  of  the  discharge  was  obscured  by  the  blood  in  it. 
Had  I  examined  the  discharge  microscopically,  gonorrhoea  would  at  once  have  been 
evident. 

It  may  be  thought  that  some  fever  is  enough  to  exclude  tubal  pregnancy 
as  the  causative  factor,  but  such  is  not  true,  for  in  many  cases  of  extrauterine 
pregnancy  with  hemorrhage  the  temperature  will  run  up  temporarily  to  102° 
and  higher.  The  following  is  a  case  in  point:  Mrs.  P.,  aged  31,  admitted 
to  the  Gynecologic  Department  of  Washington  University  Hospital.  On  ad- 
mission her  temperature  was  101.4  and  pulse  140.  She  gave  a  clear  and  typical 
history,  and  the  diagnosis  of  ruptured  tubal  pregnancy  was  positive.  The 
hemorrhage  had  been  so  severe,  however,  that  she  was  in  very  poor  condi- 
tion for  operation.  The  hemoglobin  had  been  reduced  to  30  per  cent.,  which 
made  operation  or  even  anesthesia  alone  very  dangerous.  As  the  hemorrhage 
had  stopped  and  she  was  improving,  it  was  decided  to  defer  operation  until 
it  could  be  carried  out  ivith  less  danger.  The  waiting  period  was  seven  days. 
During  that  time  the  temperature  went  up  to  102°  nearly  every  day  and  one 
day  reached  103.4.  After  seven  days  the  blood  condition  had  improved 
(hemoglobin  above  40  per  cent.)  and  she  was  so  much  improved  otherwise 
that  operation  was  carried  out.  There  was  no  pus  in  the  peritoneal  cavity— 
simply  the  unabsorbed  blood.     The  patient  recovered  promptly. 

Miscarriage  with  Abnormalities.  Various  conditions  associated  with  mis- 
carriage may  lead  to  a  mistaken  diagnosis  of  tubal  pregnancy— for  example, 
an  old  inflammatory  mass  or  a  tumor. 

Miscarriage  and  Ovarian  Tumor.— Reported  by  Brown.  A  patient  who  had  missed 
the  menstruation  for  three  weeks,  and  had  all  the  symptoms  of  pregnancy,  was  at- 
tacked with  pains  through  the  lower  abdomen.  A  physician  was  called  and  found  the 
patient  confined  to  bed,  with  abdominal  pain,  partial  suppression  of  urine,  tempera- 
ture of  102.5°,  and  evidently  severe  inflammation  from  some   cause. 


782  EXTRA-UTERINE  PREGNANCY 

Examination. — The  uterus  was  found  pushed  back  by  a  large  mass  in  the  right 
side  of  the  pelvis.  The  physician  watched  the  case  for  four  or  five  days,  and  felt  con- 
fident that  the  trouble  was  tubal  pregnancy,  with  rupture,  hemorrhage,  and  resulting 
inflammation.    Dr.  Brown,  who  was  asked  to  see  the  case,  made  the  same  diagnosis. 

Operation. — This  revealed  an  ovarian  cyst  and  general  peritonitis.  Exploration  of 
the  interior  of  the  uterus  showed  that  there  had  been  a  recent  abortion.  The  mis- 
carriage was  evidently  the  cause  of  the  peritonitis,  which  eventually  proved  fatal. 

Miscarriage  and  Broad-Ligament  Tumor. — Reported  by  Fortun.  This  case  presented 
practically  the  same  features  as  the  preceding  one — namely,  missed  menses,  abdomi- 
nal pain,  bloody  discharge  and  a  tender  mass  beside  the  uterus.  Diagnosis,  extrauter- 
ine pregnancy.  Operation  demonstrated  that  the  symptoms  were  due  to  a  tumor 
(sarcoma)    of  the  broad   ligament,  associated  with  an  abortion. 

Pregnancy  with  Abnormalities.  There  are  various  anomalous  conditions 
that  may  cause  an  intrauterine  pregnancy  to  simulate  an  extra-uterine  preg- 
nancy. 

Pregnancy  with  Hydatidiform  iViole. — Mrs.  S.,  aged  21,  came  into  my  service  at  the 
St.  Louis  Mullanphy  Hospital  with  a  diagnosis  of  extrauterine  pregnancy.  There  had 
been  no  menstruation  for  two  months,  and  there  were  the  usual  symptoms  of  early 
pregnancy.  Recently  the  patient  had  been  having  attacks  of  pain  in  the  lower  abdo- 
men, accompanied  by  a  bloody  discharge.  These  attacks  of  pain  had  been  irregular — 
at  times  severe  and  confining  her  to  bed,  while  at  other  times  she  was  able  to  be 
about  the  house.  Finally  they  became  so  disabling  that  she  was  brought  to  the  hos- 
pital. 

Examination. — When  I  saw  her  she  was  confined  to  bed,  with  a  mass  the  size  of  an 
orange  pushing  forward  the  anterior  abdominal  wall  just  above  the  pubes.  The  mass 
was  firm,  painful  on  pressure,  partially  fixed,  and  it  was  here  that  the  patient  located 
the  pain  and  distress.  There  was  a  bloody  vaginal  discharge.  Temperature,  pulse  and 
respiration  were  practically  normal.  On  bimanual  examination  the  deeper  portion  of 
the  mass  could  be  made  out,  and  it  was  found  to  be  the  size  of  a  child's  head.  Indis- 
tinct fluctuation  was  obtained.  The  body  of  the  uterus  could  not  be  made  out,  but  the 
impression  obtained  was  that  the  mass  lay  in  front  of  the  corpus  uteri,  which  was. 
pushed,  backward  and  could  not  be  felt  on  account  of  the  mass.  The  forward  projec- 
tion of  the  mass  against  the  abdominal  wall  was  very  marked. 

I  was  inclined  to  agree  with  the  diagnosis  of  extrauterine  pregnancy,  but  was  not 
entirely  satisfied,  as  I  had  not  located  certainly  the  body  of  the  uterus.  I  concluded  to 
watch  the  case  for  a  while.  The  patient  was  kept  absolutely  quiet  and  sedatives  were 
given  as  needed  for  the  pain.  The  patient  was  better  for  a  time,  but  later  the  pain  re- 
curred. It  troubled  her  every  day,  at  times  quite  severely,  but  could  not  be  identified 
as  uterine  contraction  pains.  No  variation  in  the  consistency  of  the  mass  was  noticed. 
The  bloody  discharge  continued.  A  few  very  small  clots  were  noticed,  but  no  mem- 
branes or  shreds.  I  continued  the  observation  for  ten  days,  and  the  longer  I  observed 
the  more  confusing  the  conditions  became.  The  process,  whatever  it  was,  was  pro- 
gressing rather  rapidly.  In  the  ten  days  the  mass  had  enlarged  decidedly  and  the  pain 
had  increased — so  much  so  that  at  the  end  of  the  period  it  was  evident  that  something 
must  be  done,  as  further  prolongation  of  the  trouble  would  seriously  weaken  the  pa- 
tient, who  was  not  very  strong  at  the  beginning.  The  crucial  point,  which  so  far  I 
had  been  unable  to  decide,  was  whether  the  mass  was  uterine  or  extrauterine. 

Operation. — I  decided  to  examine  the  patient  under  anesthesia,  having  everything 
ready  to  operate  in  case  the  mass  proved  to  be  extrauterine.  Under  the  complete  relaxa- 
tion of  anesthesia  I  was  able  to  determine  that  the  cervix  expanded  symmetrically  into 
the  mass,  which  was  thus  identified  as  the  body  of  the  uterus.  It  was  found,  however,  to 


CONDITIONS  SIMULATING  TUBAL  PREGNANCY  783 

be  twice  as  large  as  it  should  be  at  that  period  ol"  pregnancy.  This  abnormal  enlarge- 
ment with  the  prolonged  bloody  discharge  and  the  increasing  pain  made  it  evident  that 
there  was  some  serious  pathologic  condition  within  the  uterus  and  not  a  normal  preg- 
nancy. I  dilated  the  cervix  slightly,  and  there  escaped  several  small  cysts.  That  made 
the  diagnosis  plain,  and  I  then  dilated  the  cervix  widely  and  removed  from  the  uterus 
a  beautiful  specimen  of  hydatidiform  mole.  The  uterine  cavity  was  literally  packed 
with  the  grape-like  bunches  of  minute  cysts  characteristic  of  this  condition.  No  trace 
of  a  fetus  as  found.  The  patient  recovered  without  further  trouble,  and  has  since 
given  birth  to  two  children,  the  pregnancy,  labor  and  puerperium  in  each  case  being 
normal. 

Pregnancy  with  Hysteria  and  Uterine  Displacement. — While  I  was  in  charge  of  our 
city  hospital  for  women  (St.  Louis  Female  Hospital)  a  patient  was  brought  into  that 
institution  on  a  stretcher,  suffering  severe  abdominal  pain  and  apparently  very  sick. 
The  suffering  was  so  great  that  the  history  was  obtained  with  difficulty.  She  had 
missed  the  menses  about  four  months,  and  the  usual  symptoms  of  pregnancy  had  been 
succeeded  by  irregular  attacks  of  pain,  which  culminated  in  the  severe  attack  which 
caused  her  to  be  hurried  to  the  hospital. 

Examination. — The  abdomen  was  sensitive  and  the  muscles  rigid.  In  the  right  lower 
abdomen  there  was  a  distinct  mass,  very  painful  to  touch.  On  bimanual  examination 
it  was  found  that  this  mass  extended  down  into  the  right  side  of  the  pelvis,  which  it 
largely  filled.  It  was  about  the  size  of  a  child's  head,  extremely  tender,  apparently 
fixed  and  presenting  indistinct  fluctuation.  The  cervix  was  somewhat  softened.  The 
body  of  the  uterus  could  not  be  made  out  on  account  of  the  marked  tenderness  and 
the  resulting  muscular  rigidity,  which  interefered  with  deep  palpation.  The  pulse  was 
rapid,  but  of  fair  volume.  There  was  no  fever.  I  was  quite  certain  that  the  trouble 
was  extrauterine  pregnancy.  Examination  under  anesthesia,  however,  showed  that  it 
was  an  intrauterine  pregnancy.  The  fixed  and  tender  mass  in  the  right  side  was  the 
pregnant  uterus,  which  was  freely  movable  under  anesthesia. 

After  the  examination  the  symptoms  largely  disappeared  and  the  patient  was  able 
to  leave  the  hospital  in  a  short  time.  The  misleading  features  were  the  severe  ab- 
dominal pain  and  tenderness,  associated  with  a  lateral  pelvic  mass,  which  was  ex- 
tremely tender  (hysterical  hyperesthesia)  and  fixed  (by  the  rigid  condition  of  the 
abdominal  muscles),  and  which  could  not  be  identified  as  the  body  of  the  uterus  (be- 
cause of  the  marked  softening  just  above  the  cervix,  and  also  because  of  the  impossi- 
bility of  deep  palpation).  Anesthesia  removed  the  difficulties  at  once  and  permitted  a 
correct  diagnosis. 

This  case  and  the  preceding  one  serve  to  emphasize  the  necessity  of  careful 
examination  under  anesthesia  before  operation  in  all  such  doubtful  or  un- 
certain cases.  It  must  be  kept  in  mind,  however,  that  when  tubal  pregnancy- 
is  suspected  the  patient  should  be  placed  in  a  hospital  and  prepared  for  opera- 
tion before  the  examination  under  anesthesia  is  made,  for  if  the  trouble  is 
tubal  pregnancy  the  manipulations  of  the  examination  may  cause  rupture  and 
hemorrhage,  requiring  immediate  operation. 

Pregnancy  with  irregular  Softening  of  Uterus. — A  patient  with  supposed  extrauterine 
pregnancy  was  brought  to  St.  Louis  by  her  physician  and  placed  under  my  care.  About 
five  months  previously  she  had  missed  her  menses  and  presented  the  usual  symptoms 
of  pregnancy.  Three  months  later  she  had  abdominal  pains  accompanied  by  a  bloody 
discharge  from  the  uterus.  The  bleeding  stopped,  but  the  pain  recurred  at  irregular 
intervals  and  there  was  an  enlarging  mass,  which  could  not  be  identified  as  part  of  the 
uterus.   Her  physician  called  several  others  in  consultation  and  the  consensus  of  opin- 


784  EXTRA-UTERINE   PREGNANCY 

ion  was  that  the  pregnancy  was  extrauterine;  hence  she  was  brought  to  St.  Louis  for 
operation. 

Examination. — I  found  a  very  puzzling  condition.  The  body  of  the  uterus  was  irregu- 
lar in  shape  and  irregularly  softened,  and  gave  at  first  the  impression  of  a  fairly  firm 
mass  not  connected  with  the  cervix,  the  portion  immediately  above  the  cervix  being 
so  softened  as  to  be  hardly  palpable.  After  examining  for  some  time  it  was  finally  de- 
termined that  the  mass  was  the  enlarged  and  pregnant  corpus  uteri.  The  rhythmical 
hardening  of  the  uterine  wall  aided  materially  in  the  differentiation.  By  prolonging  the 
examination  I  was  able  to  feel  the  previously  softened  portion  harden  under  the 
finger,  and  could  then  make  out  that  the  upper  part  of  the  cervix  expanded  sym- 
metrically into  the  mass  in  question.  After  working  out  the  diagnosis  I  was  able  to 
demonstrate  it  satisfactorily  to  the  patient's  physician,  who  examined  her  with  me. 

Pregnancy  with  Retroflexed  Uterus. — Reported  by  Royster,  aged  22,  married 
sixteen  months,  missed  her  menses  three  times  in  succession,  had  nausea  and  vomiting, 
and  also  tenderness  of  the  breasts.  Then  she  had  an  attack  resembling  cholera  morbus 
and  a  slight  bloody  stain  from  the  genitals,  but  no  distinct  hemorrhage.  The  signs  of 
pregnancy  then  became  less  marked.  She  complained  of  pain  in  the  lower  abdomen, 
especially  in  the  left  side,  and  of  frequent  and  painful  urination. 

Examination. — There  was  found  a  mass  chiefly  in  the  left  side  of  the  pelvis  and 
pressing  down  the  posterior  vaginal  fornix.  It  was  boggy  and  tender  to  the  touch. 
The  uterus  appeared  to  be  pushed  to  the  right  side  and  was  intimately  associated  with 
the  mass.  A  sound  was  readily  introduced  into  the  uterus  to  the  depth  of  three  inches, 
indicating  that  the  uterus  was  about  normal  in  depth  and  was  empty.  A  diagnosis  of  ex- 
trauterine pregnancy  was  made  and  the  patient  operated  on  accordingly. 

Operation. — This  revealed  a  retroverted  pregnant  uterus,  twisted  somewhat  toward 
the  left,  and  with  the  wall  softened  irregularly.  There  was  no  extrauterine  pregnancy. 
The  uterus  was  brought  into  correct  position  and  a  small  cyst  of  the  ovary  removed. 
The  patient  recovered  without  incident  and  the  pregnancy  continued. 

Pregnancy  and  Salpingitis. — Reported  by  Leopold.  Patient,  aged  32,  mother  of  five 
children,  missed  menstruation  and  had  abdominal  pains  and  bloody  discharge.  Ex- 
amination showed  a  painful  mass  occupying  the  posterior  cul-de-sac.  Diagnosis,  ex- 
trauterine pregnancy.  Operation  revealed  an  intrauterine  pregnancy,  with  an  asso- 
ciated salpingo-oophoritis,  probably  of  gonorrhoeal  origin.  The  mass  formed  by  the 
inflamed  tube  and  ovary  was  low  in  the  cul-de-sac.    Patient  recovered. 

Pregnancy  with  Torsion  of  Enlarged  Tube. — Reported  by  Morel.  Patient,  aged  32, 
mother  of  four  children,  missed  menstruation.  After  a  time  she  was  seized  with  severe 
pain  in  the  left  lower  abdomen,  had  vomiting,  rapid  pulse  and  no  fever.  The  uterus 
was  somewhat  enlarged  and  softened,  and  a  tumor  was  felt  back  of  it.  Operation 
showed  a  pregnant  uterus  with  a  posterior  mass,  as  large  as  a  turkey's  egg,  formed  by 
the  left  tube.  The  pedicle  of  the  enlarged  tube  was  twisted  six  times  and  the  interior 
was  filled  with  blood   (hematosalpinx). 

Tumor  with  Anomalous  Symptoms.  When  a  pelvic  tumor,  previouslj'-  un- 
recognized, happens  to  be  accompanied  with  missed  menstruation  and  sudden 
pain  and  decided  tenderness,  the  resemblance  to  tubal  pregnancy  may  be  most 
misleading. 

Broad  Ligament  Cyst,  with  Intracystic  Hemorrhage. — Mrs.  D.,  aged  26,  admitted  to 
the  Gynecologic  Department  of  Washington  University  Hospital.  Married  five  months. 
Previous  menstrual  history  normal — menses  regular  in  appearance,  duration  four  days, 
no  pain.  One  month  after  marriage  menstruation  was  missed  for  seven  days.  Then 
a  bloody  flow  appeared.  It  was  profuse,  accompanied  by  clots  and  lasted  about  nine 
days.    About  two  weeks  later  the  patient  had  a  fall,  which  was  followed   by  pain  in 


CONDITIONS   SIMULATING  TUBAL   PREGNANCY  785 

the  left  side  of  the  pelvis  and  lower  abdomen,  and  this  persisted.  The  succeeding 
months  there  was  a  menstrual  flow,  but  it  was  less  than  the  usual  amount.  The  pa- 
tient continued  sick,  and  had  to  give  up  work  and  was  obliged  to  lie  down  at  times.  There 
was  loss  of  appetite  and  for  two  months  decided  nausea  when  riding  in  a  car,  but 
this  became  less.  There  was  also  tenderness  of  the  breasts,  which  had  diminished 
during  the  last  month.  There  had  been  no  fever.  The  patient  complained  of  pain  in 
the  left  lower  abdomen.    Temperature  was  99°,  pulse  90,  and  respiration  20. 

Examination. — The  uterus  was  found  forward,  to  the  right  and  movable.  The  left 
side  of  the  pelvis  was  occupied  by  a  mass  the  size  of  a  large  orange,  fluctuating  and 
tender  on  palpation.  The  diagnosis  was  doubtful,  with  the  probability  in  favor  of  tubal 
pregnancy. 

Operation.— This  revealed  a  parovarian  tumor  (cyst)  into  which  hemorrhage  had  taken 
place.  The  cyst  was  easily  enucleated  from  its  bed  in  the  broad  ligament,  and  sub- 
sequent examination  of  it  in  the  laboratory  positively  excluded  extrauterine  pregnancy. 
The  patient  recovered  without  particular  incident. 

Parovarian  Cyst  with  Twisted  Pedicle  and  Salpingitis. — Patient,  aged  22,  admitted  to 
Gynecologic  Department  of  Washington  University  Hospital,  very  111  and  complain- 
ing of  pains  through  the  lower  abdomen. 

Examination. — A  large  mass  was  found,  filling  the  right  side  of  the  pelvis  and  ex- 
tending up  into  the  lower  abdomen,  half  way  to  the  umbilicus.  This  was  painful  on 
palpation  and  indistinct  fluctuation  could  be  made  out.  The  uterus  was  pushed  to  the 
left.  All  the  pelvic  structures  were  apparently  bound  together  and  fixed  by  adhesions. 
Patient  was  pale  and  complained  of  a  constant  pain  in  the  abdomen,  of  a  dull  char- 
acter. Temperature,  99°;  pulse,  80;  respiration,  20.  For  ten  weeks  past  the  menstrua- 
tion had  been  very  irregular.  For  nearly  a  month  there  was  a  constant  bloody  dis- 
charge, then  it  stopped  for  a  few  days,  then  came  on  again  for  a  few  days,  and  then 
stopped  entirely.  For  five  weeks  before  entering  the  hospital  there  was  no  menstrua- 
tion, not  even  a  trace  of  blood.  There  was  free  mucopurulent  discharge.  During  the 
period  mentioned  there  had  been  considerable  pain  throughout  the  abdomen,  and  two 
weeks  before  entering  the  hospital  the  patient  had  had  a  very  severe  attack  of  pain. 
She  was  confined  to  bed  for  a  few  days  and  had  been  lying  down  off  and  on  ever 
since.  The  mass  was  too  large  and  of  too  rapid  development  to  be  due  to  the  inflam- 
mation, which  was  apparently  of  mild  grade.  There  was  no  previous  history  of  a  tumor. 
There  had  been  some  pain,  off  and  on,  during  the  previous  year,  but  nothing  to  suggest 
serious  trouble. 

The  patient  was  kept  under  observation  for  seven  days.  The  temperature  ranged 
from  98°  to  99.4°,  once  going  to  100°,  but  never  higher.  The  pulse  ranged  from  80  to  92. 
The  mass  continued  to  enlarge  and  the  pain  increased,  requiring  sedatives,  in  spite  of 
the  fact  that  the  patient  was  kept  absolutely  quiet  in  bed  and  that  the  temperature 
continued  low.  There  had  been  a  tentative  diagnosis  of  tubal  pregnancy,  and  this 
progress  under  observation  and  the  continued  absence  of  the  menstruation  tended  to 
confirm  it. 

Operation. — The  mass  was  found  to  be  a  parovarian  cyst  with  twisted  pedicle,  uni- 
versal adhesions  and  a  complicating  pyosalpinx  of  the  same  side.  Free  drainage  was 
employed  and  the  patient  recovered. 

Abdominal  Pain  and  Collapse. 

"When  a  married  woman  in  the  child-bearing  period  is  seized  with  severe 
abdominal  pains,  without  apparent  cause,  and  passes  into  the  condition  of  col- 
lapse associated  with  severe  internal  hemorrhage,  we  naturally  think  of  rup- 
tured tubal  pregnancy  as  the  most  probable  cause.  If  there  happens  to  be 
missed  menstruation  or  some  of  the  other  symptoms  of  tubal  pregnancy,  and 


786  EXTRA-UTERINE  PREGNANCY 

the  examination  reveals  nothing  else  to  account  for  the  pain  and  shock,  a 
tentative  diagnosis  of  tubal  pregnancy  and  action  accordingly  is  certainly 
justified.  As  prompt  action  may  be  necessary  to  save  the  patient's  life,  such 
action  must  sometimes  be  taken  on  evidence  which  would  be  considered  insuf- 
ficient were  the  indications  less  urgent.  Under  such  conditions  the  diagnosis 
of  ruptured  tubal  pregnancy  is  largely  a  matter  of  exclusion,  for,  as  previously 
stated,  the  pelvic  examination  often  gives  no  definite  evidence  beyond  the  ten- 
derness. Hence  the  importance  of  carefully  considering  other  conditions  tha" 
may  cause  these  symptoms.  There  are  many  such  conditions,  but  I  shall  men- 
tion only  certain  ones  which  are  especially  liable  to  be  confounded  with  rup- 
tured tubal  gestation. 

Hemorrhage  from  Ovary. — Weinbrenner  reports  two  cases  in  which  hemorrhage  into 
a  corpus  luteum,  already  in  cystic  degeneration,  burst  the  wall  of  the  cyst.  Free  hem- 
orrhage into  the  peritoneal  cavity  followed.  In  one  instance  the  tendency  to  hemorrhage 
was  increased  by  torsion  of  the  pedicle  of  the  cystic  ovary.  The  clinical  diagnosis  in 
each  case  was  extrauterine  pregnancy,  'but  microscopic  examination  of  the  removed 
specimen  showed  positively  that  there  was  no  pregnancy. 

In  cases  of  ovarian  hemorrhage,  care  must  be  taken  to  exclude  ovarian 
pregnancy  at  the  site  of  the  hemorrhage  before  deciding  that  it  is  due  to 
some  other  condition.  Some  of  the  so-called  "blood  cysts"  of  the  ovary 
are,  no  doubt,  uurecognized  instances  of  ovarian  pregnancy.  The  following 
is  a  case  in  point :  Reported  by  J.  K.  Kelly.  He  operated  on  a  woman,  aged 
33,  for  supposed  extrauterine  pregnancy  and  found  only  a  blood  cyst  of  the 
ovary  about  the  size  of  a  plum.  The  ovary  was  removed  and  the  case  set 
down  as  one  of  mistaken  diagnosis.  Some  months  later,  and  quite  incidentally, 
a  microscopic  section  "\vas  made  through  the  wall  of  the  little  cyst,  and  exami- 
nation of  this  showed  chorionic  villi.  A  careful  and  systematic  examination 
was  then  made  of  the  small  cyst  and  its  surroundings,  and  it  proved  to  be  a 
beautiful  specimen  of  early  ovarian  pregnancy. 

Ovarian  Cyst  with  Rupture. — Reported  by  Vineberg.  In  his  office  he  was  examining 
a  woman  on  account  of  discomfort  in  the  lower  abdomen  associated  with  delayed  men- 
struation. The  patient  was  stout  and  the  bimanual  examination  was  difficult.  The 
uterus  was  enlarged  and  to  the  left  of  it  was  a  cystic  mass  the  size  of  a  small  orange. 
While  palpating  this  mass  it  suddenly  ruptured  and  the  patient  promptly  went  into 
syncope.  It  was  supposed  that  a  tubal  gestation  sac  had  ruptured,  with  resulting  in- 
traperitoneal hemorrhage.  After  a  little  time  the  patient  rallied,  and  as  the  symptoms 
were  then  not  so  urgent  she  was  kept  under  observation  for  a  couple  of  days.  Im- 
provement was  so  marked  that  it  was  decided  that  the  ruptured  mass  must  have 
been  only  a  small  cyst  of  the  ovary  instead  of  a  tubal  pregnancy.  There  was  no  fur- 
ther trouble. 

Hematosalpinx  with  Severe  Bleeding. — Brettauer  reported  a  case  of  severe  internal 
hemorrhage,  supposedly  due  to  ruptured  tubal  pregnancy.  The  patient  went  into  col- 
lapse and  became  too  weak  for  operation.  Later  she  rallied  and  the  operation  was  car- 
ried out.  A  hemorrhagic  swelling,  the  size  of  a  walnut,  was  found  in  the  middle  third 
of  one  tube.  From  this  the  severe  bleeding  had  taken  place.  The  inner  and  outer  por- 
tion of  the  tube  were  apparently  normal.    The  swollen  area  had  the  appearance  of  a 


CONDITIONS   SIMULATING   TUBAL   PREGNANCY  787 

tubal  pregnancy  and  was  excised  as  such.  When  sectioned  and  examined  microscopic- 
ally no  tubal  pregnancy  was  found.  The  specimen  was  then  sectioned  serially  and 
examined  most  carefully,  and  the  result  was  absolutely  negative  so  far  as  evidence  of 
tubal  pregnancy  was  concerned. 

The  fact  is  sometimes  overlooked  that  tubal  swellings  of  hemorrhagic  character  are 
not  necessarily  due  to  pregnancy  in  that  situation.  Since  Tait's  famous  dictum,  that 
"hematosalpinx  is  always  due  to  extrauterine  pregnancy,"  there  has  been  a  tendency 
among  operators  to  look  On  this  as  a  rule  without  exceptions.  That  there  are  excep- 
tions, however,  there  is  abundant  proof.  A  number  of  well-established  cases  have  been 
reported.  As  a  rule,  such  differentiation  is  not  of  great  practical  moment,  for  the  rea- 
son that  treatment  of  the  two  conditions  is  the  same — namely,  removal  of  the  damaged 
tube.  In  some  cases,  however,  it  may  be  extremely  important  to  determine  certainly 
the  character  of  the  mass  before  expressing  an  opinion  as  to  what  it  is.  Such  an  inr 
stance  came  to  my  notice.  I  was  not  connected  w'ith  the  case,  but  was  apprised  of  the 
facts  afterward.  Some  years  ago  a  pupil  nurse  in  one  of  our  hospitals  was  attacked 
with  serious  abdominal  disturbance  requiring  operation.  When  the  abdomen  was 
opened  there  was  found  a  hemorrhagic  condition  of  one  tube  resembling  tubal  preg- 
nancy. The  operator  at  once  pronounced  it  tubal  pregnancy  in  the  presence  of  several 
internes  and  nurses.  The  information  spread  through  the  hospital  with  a  result  to 
be  easily  imagined.  The  young  woman  recovered  from  the  serious  operation  only  to 
find  herself  in  a  situation  almost  unbearable,  and  she  finally  left.  In  the  meantime, 
examination  of  the  mass  by  a  competent  pathologist  showed  that  it  was  not  a  tubal 
pregnancy  and  that  a  most  serious  mistake  had  been  made  in  pronouncing  it  such. 

Tubo-ovarian  Hemorrhage. — Bovee  reported  a  case  in  W'hich,  at  operation,  there  was 
found  a  tubo-ovarian  hemorrhagic  mass,  supposed  to  be  tubal  pregnancy,  but  which 
proved  to  be  only  infiammatory.  Both  the  tube  and  ovary  were  distended  with  blood, 
and  there  was  a  small  opening  through  the  fimbriated  extremity  connecting  the  two 
cavities.  The  hemorrhage  apparently  originated  in  the  ovary,  and  the  free  intraperi- 
toneal bleeding  came  through  a  small  rupture  in  the  wall  of  the  ovarian  blood-cyst. 
A  thorough  microscopic  examination  demonstrated  that  there  was  no  pregnancy  either 
in  the  tube  or  ovary. 

Bovee  mentioned  eases  of  tubal  and  ovarian  liemorrliage,  not  due  to  ex- 
trauterine pregnancy,  reported  by  Price,  Newman,  Griffiths,  Briggs,  Groom, 
Paul,  Ruge,  Goodell,  Duncan,  Pilliet,  Maurange,  Peucli  and  Doran.  He  re 
f  erred  also  to  cases  occurring  in  virgins  at  an  early  age,  reported  by  Fordyce ; 
to  fatal  cases  reported  by  Walter,  Lewis  and  Fowler;  to  cases  successfully 
treated  by  abdominal  section,  reported  by  Boldt,  Alloway,  Knaggs,  and 
Johnson,  and  to  the  celebrated  cases  of  Scanzoni  in  wdiich  at  an  autopsy  on  the 
body  of  a  young  girl,  dying  suddenly  during  menstruation,  three  liters  of 
blood  was  found  in  the  peritoneal  cavity.  These  hemorrhages  from  the 
non-pregnant  ovary  (ovarian  apoplexy,  blood-cysts,  follicular  hemorrhage, 
etc.)  and  from  the  non-pregnant  tube  (hematosalpinx)  are  usually  due  to 
inflammatory  changes,  causing  degeneration  of  the  tissues  and  of  the  con- 
tained blood  vessels.  Occasionally  a  tumor  of  the  ovary  or  tube  is  the 
causative  lesion. 

Many  other  conditions  have  been  mistaken  for  tubal  pregnancy  (on  account 
of  sudden  collapse  associated  with  abdominal  pain) — for  example,  hemorrhage 
from  a  varicose  vein  of  the  broad-ligament,  salpingitis  with  collapse,  per- 
forative appendicitis   with   a  pelvic   tumor,   and  fulminating  pelvic   edema. 


788  EXTRA-UTERINE  PREGNANCY 

Numerous  illustrative  cases  have  been  reported,  but  there  is  not  space  for 
these  here.     Fulminating  pelvic  edema  will  be  considered  later   (page  795). 

Conclusions. 

1.  Gonorrhoeal  pyosalpinx,  after  the  acute  symptoms  subside,  may  lie  dor- 
mant and  unsuspected  for  a  long  period  (four  years  in  one  reported  case). 
During  this  quiescent  period  the  pus-tube  (containing  sterile  pus  usually)  is 
tolerated  the  same  as  a  small  tumor  or  other  non-irritating  body — the  patient 
being  practically  well  and  without  decided  pelvic  disturbance. 

Such  a  quiescent  pus-tube  may  at  any  time  give  rise  to  an  acute  exacerba- 
tion, and  the  onset  of  the  pain  may  be  so  sudden  and  apparently  causeless 
as  to  suggest  tubal  pregnancy.  This  suggestion  is  strengthened  by  the  con- 
tinued enlargement  of  the  mass  (from  irritative  exudate)  without  decided 
fever  (for  the  pus  is  sterile).  Accompanying  the  exacerbation  or  preceding  it 
there  are  sometimes  other  symptoms  that  we  associate  with  tubal  pregnancy — 
viz.,  missed  menstruation,  stomach  disturbance,  tenderness  of  the  breasts, 
and  softening  of  the  cervix  uteri.  The  last  three  are  accounted  for  by  the 
peritoneal  and  periuterine  irritation  and  congestion,  but  why  there  should 
be  delayed  or  missed  menstruation  at  this  inopportune  time  I  do  not  know. 
One  would  suppose  that  the  irritation  and  pelvic  congestion  would  cause 
the  menstrual  flow  to  be  excessive  rather  than  absent.  It  is  possible  that  the 
temporary  suppression  of  menstruation  (from  some  nervous  disturbance  or 
other  obscure  cause)  stands  in  a  causative  relation  to  the  acute  exacerbation 
with  its  subsequent  symptoms.  I  offer  this  simply  as  a  suggestion  toward 
a  possible  explanation  of  this  strange  and  misleading  sequence  of  events 
(the  missed  menstruation  followed  by  the  other  symptoms  detailed). 

In  cases  of  supposed  tubal  pregnancy  of  the  type  mentioned  particular  care 
should  be  taken  to  exclude  chronic  gonorrhoeal  salpingitis,  as  follows:  (a) 
by  inquiring  into  the  patient's  history  for  evidences  of  specific  vaginitis  or 
urethritis,  and  for  subsequent  pelvic  symptoms  (an  inquiry  into  the  hus- 
band's history  also  may  bring  out  valuable  information)  ;  (b)  by  a  careful 
examination  for  evidences  of  a  chronic  urethritis.  Bartholinitis,  endometritis 
or  salpingitis;  and  (c)  by  staining  for  the  gonococcus  any  suspicious  discharge 
that  may  be  obtained  from  the  urethra,  vulvovaginal  glands,  uterus  or  vagina. 
In  chronic  cases  negative  findings  do  not  exclude  gonorrhoea,  for  the  gonococ- 
cus disappears  from  the  discharge  after  a  time. 

2.  In  rare  cases  acute  gonorrhoea  may  extend  rapidly  through  the  uterus 
to  the  tubes  and  peritoneum,  with  so  little  disturbance  of  the  vagina  and  vulva 
as  to  arouse  no  suspicion  of  its  presence.  In  such  a  case  the  acute  peritoneal 
symptoms  will  come  on  suddenly  and  witliout  apparent  cause.  If  there  hap- 
pens to  be  also  delayed  or  scanty  menstruation,  tubal  pregnancy  may  be  sus- 
pected. And  this  suspicion  is  strengthened  by  the  stomach  disturbance,  the 
softening  of  the  cervix  and  the  enlarging  mass  beside  the  uterus.  In.  my 
case  above  mentioned  the  diagnosis  was  further  obscured  by  the  curetment, 
which  modified  the  discharge,  and  by  the  continued  low  temperature,  which 


CONDITIONS   SIMULATING   TUBAL   PREGNANCY  789 

seemed  to  exclude  acute  inflammation.  In  all  such  doubtful  cases  with  acute 
discharge  it  is  advisable  to  examine  for  gonococci,  even  though  the  discharge 
be  scanty  and  bloody  and  apparently  non-purulent. 

3.  An  early  miscarriage,  if  associated  with  a  tumor  or  followed  by  mild 
salpingitis,  may  very  closely  simulate  tubal  pregnancy.  IMembranes  may 
be  passed  in  either  condition.  With  a  miscarriage  there  is  an  embryo,  but  it 
often  passes  unnoticed.  If  a  shred  of  tissue  is  passed,  it  may  be  examined  for 
chorionic  structures.  In  a  case  which  can  not  be  decided  otherwise,  curet- 
ment  is  advisable  to  obtain  tissue  for  microscopic  examination  for  chorionic, 
villi.  But  in  suspected  tubal  pregnancy  such  a  curetment  should  not  be 
carried  out  until  the  patient  is  in  a  hospital  and  prepared  for  abdominal  sec- 
tion, for  the  manipulations  may  start  internal  hemorrhage,  requiring  opera- 
tion at  once. 

4.  A  pregnant  uterus  may  present  very  misleading  conditions — e.  g.,  irregu- 
lar softening  (so  much  so  that  the  body  seems  to  be  a  firm  mass  entirely 
separate  from  the  cervix),  displacement,  backward  or  forward  or  laterally; 
hyperesthesia  with  displacement,  or  irregular  softening  or  an  associated 
lateral  mass  (salpingitis,  etc.).  If  there  is  in  addition  an  anomalous  history, 
a  mistake  is  quite  probable. 

5.  An  unsuspected  tumor  in  the  pelvis  may  give  rise  suddenly  to  severe 
disturbance,  and  if  there  happen  to  be  present  also  some  of  the  symptoms  of 
early  pregnancy,  a  diagnosis  of  extrauterine  pregnancy  is  very  probable. 
The  cases  mentioned  above  show  that  the  early  symptoms  of  pregnancy 
(missed  menstruation,  stomach  disturbance,  breast  tenderness  and  softened 
cervix  uteri)  often  appear  without  satisfactory  cause  and  at  most  inoppor- 
tune times. 

6.  Ovarian  hemorrhage  or  tubal  hemorrhage,  due  to  other  conditions,  may 
so  closely  simulate  extrauterine  pregnancy  as  to  be  indistinguishable  before 
operation,  and  in  some  cases  the  matter  is  in  doubt  even  after  direct  ex- 
posure and  handling  of  the  affected  structures.  In  this  connection  there  are 
three  points  to  be  kept  in  mind:  (a)  There  may  be  slight  hemorrhage  from 
the  tube  or  ovary,  particularly  at  the  period  of  menstrual  congestion,  not  due 
to  extrauterine  pregnancy  and  not  requiring  operation,  (b)  In  cases  of  tubal 
hemorrhage  requiring  operation  the  hemorrhagic  condition  of  the  tube  is 
not  necessarily  due  to  pregnancy,  and  in  doubtful  cases  should  not  be  pro- 
nounced such  until  after  confirmation  by  microscopic  examination,  (c)  In 
a  hemorrhagic  condition  of  the  ovary  requiring  removal  of  the  same,  a 
careful  examination  should  be  made  to  determine  exactly  the  pathologic  con- 
dition. Such  a  supposed  simple  "blood  cyst"  of  the  ovary  may  prove  on 
careful  microscopic  examination  to  be  an  early  ovarian  pregnancy. 

7.  Salpingitis,  appendicitis  and  perforations  in  the  gastro-intestinal  tract 
may,  in  rare  cases,  come  on  so  suddenly  and  progress  so  rapidly  as  to  sug- 
gest internal  hemorrhage  from  extrauterine  pregnancy.  Usually  in  these 
conditions  there  are  preceding  or  accompanying  symptoms  which  point  to 
the  true  nature  of  the  disease.    If  these  distinctive  features  are  absent  and 


790  EXTRA-UTERINE  PREGNANCY 

there  happen  to  be  some  of  the  other  symptoms  of  tubal  pregnancy,  a  mis- 
taken diagnosis  is  probable. 

8.  Fulminating  pelvic  edema,  with  its  sudden  onset  and  the  rapid  develop- 
ment of  alarming  symptoms,  may  closely  resemble  extrauterine  pregnancy. 
In  my  own  case,  cited  later,  the  temperature  was  so  high  that  it  was  easily 
distinguished  as  an  inflammatory  trouble  and  not  a  hemorrhage,  but  in  other 
reported  cases  this  feature  was  lacking  and  mistaken  diagnoses  of  extrauter- 
ine pregnancy  were  made.  In  this,  as  in  other  conditions  of  non-hemorrhagic 
shock  or  depression,  there  is  not  the  persistently  blanched  condition  of  the 
skin  so  characteristic  of  profuse  hemorrhage.  The  pulse,  also,  though  rapid, 
is  likely  to  have  better  volume  than  after  a  severe  hemorrhage. 

9.  It  is  evident  that  the  diagnosis  of  extrauterine  pregnancy  must  rest  on 
the  combination  of  several  symptoms.  No  one  fact  is  sufficient,  and  it  is 
hazardous  to  depend  on  two  or  three  facts  unless  they  are  especially  strong 
and  well  marked.  In  most  cases  the  diagnosis  must  be  reached  by  a  careful 
consideration  of  all  the  symptoms  present  and  the  definite  exclusion,  one  by 
one,  of  other  conditions  which  may  produce  similar  symptoms. 

TREATMENT. 

In  pointing  out  the  treatment  for  extrauterine  pregnancy,  several  clinical 
classes  must  be  considered — namely  (1)  before  rupture,  (2)  hematocele, 
(3)  repeated  moderate  intraperitoneal  hemorrhage,  (4)  profuse  intraperi- 
toneal hemorrhage,  (5)  hematoma,  and  (6)  advanced  cases. 

1.  Before  Rupture.  The  only  safe  line  of  treatment  in  this  stage  is  ab- 
dominal section  and  removal  of  the  pregnant  tube  as  soon  as  the  diagnosis 
is  fairly  certain.  The  patient  is  in  constant  danger  of  a  sudden  serious 
hemorrhage,  hence  the  sooner  she  is  operated  on  the  better.  If  the  tube  is 
lying  low  in  the  cul-de-sac,  it  might  be  reached  and  ligated  from  below 
(vaginal  section),  but  this  is  not  an  entirely  safe  undertaking.  The  manipu- 
lations may  serve  to  start  a  sudden  severe  hemorrhage  which  could  not  be 
promptly  checked  from  below,  particularly  as  these  pregnant  tubes  are  fre- 
quently bound  in  place  by  old  adhesions.  The  safest  operation  in  this  stage 
is  removal  of  the  pregnant  tube  by  abdominal  section. 

2.  Pelvic  Hematocele  (Fig.  662).  In  these  cases  the  hemorrhage  has  long 
since  ceased  and  the  collection  of  blood  in  the  pelvic  cavity  is  well  shut  off 
from  the  general  peritoneal  cavity  by  plastic  exudate  and  adhesions.  The 
embryo  and  membranes  have  probably  escaped  from  the  tube,  either  through 
a  rupture  in  the  wall  -or  more  frequently  through  the  end  of  the  tube  by 
"tubal  abortion,  "and  perhaps  have  been  largely  absorbed. 

Practically  all  that  remains  is  the  blood  in  the  pelvis,  with  the  exudate  end 
adhesions  around  it.  This  forms  a  tender  mass  low  in  the  cul-de-sac  back  of 
the  uterus,  without  much  disturbance  higher. 

In  such  a  case  it  is  well  to  watch  the  patient  for  a  while,  in  the  meantime 
keeping  her  quiet  in  bed.  In  the  course  of  a  week  or  ten  days  there  will 
probably  be  decided    improvement,  showing    that  nature  is  taking    care  of 


TREATMENT  79]_ 

the  blood  aud  exudate  and  that  the  patient  will  prol)ably  recover  without 
operation,  or  renewed  evidences  of  irritation  will  appear,  showing  that  em- 
bryo and  membranes  are  still  growing  or  that  the  blood  and  exudate  is  act- 
ing as  a  persistent  source  of  irritation.  "When  there  is  persistent  irritation 
after  this  period  of  rest,  operation  is  indicated. 

The  choice  of  operation  depends  on  the  circumstances  of  the  case.  If  the 
evidences  of  irritation  (pain  and  tenderness)  are  all  low  in  the  cul-de-sac, 
the  probability  is  that  evacuation  of  the  blood  from  the  cul-de-sac  by  vaginal 
section  will  be  all  that  is  necessary.  If  the  pain  and  tenderness  extend  into 
the  upper  part  of  the  pelvis,  abdominal  section  is  the  safer  operation.  "When 
the  conditions  are  doubtful,  the  abdominal  route  should  be  chosen. 

In  a  case  where  a  hematocele  is  to  be  evacuated  by  vaginal  section,  the 
patient  should  be  prepared  for  an  abdominal  section  also,  for  there  is  a  pos- 
sibility of  the  vaginal  manipulations  starting  an  internal  hemorrhage  which 
could  not  be  satisfactorily  controlled  from  below. 

3.  Repeated  Moderate  Intraperitoneal  Hemorrhage  (Fig.  663).  This  class 
comprises  the  majority  of  the  cases  of  tubal  pregnancy.  The  usual  course  of 
such  a  case  is  well  shown  in  the  typical  case  previously  described  (page  774) , 
The  treatment  is  abdominal  section  as  soon  as  the  diagnosis  is  positive  and 
the  patient  can  be  gotten  to  a  hospital  and  given  the  regular  careful  prepara- 
tion for  that  operation. 

4.  Profuse  Intraperitoneal  Hemorrhage  (Figs.  664,  665).  In  these  cases  im- 
mediate abdominal  section  is  advisable  as  a  rule  if  the  patient  is  within  reach 
of  an  experienced  abdominal  surgeon  and  can  be  gotten  into  suitable  sur- 
roundings. In  the  absence  of  an  experienced  operator  and  suitable  facilities, 
operation  had  best  be  deferred. 

In  operations  for  the  various  classes  of  cases  of  extrauterine  pregnancy,  as 
well  as  other  conditions  in  which  abdominal  section  is  required,  the  patient's 
chance  of  recovery  is  greater  if  the  operation  can  be  conducted  in  a  well- 
ordered  hospital.  Consequently,  the  patient  should  be  taken  to  a  hospital 
if  possible.  Even  a  trip  on  the  train,  with  the  patient  on  a  stretcher  and  in 
a  strictly  recumbent  posture  all  the  time,  is  less  hazardous  than  operation 
in  poor  surroundings.  The  marked  emphasis  which  teachers  and  writers  gen- 
erally have  placed  upon  promptness  of  operation  in  extrauterine  pregnancy 
has  unfortunately  led  to  considerable  indiscriminate  operating  in  these 
cases — operations  on  patients  in  which  it  would  have  been  safer  to  wait  a 
while,  operations  without  adequate  antiseptic  preparation,  operations  by  per- 
sons without  sufficient  surgical  experience  to  handle  the  serious  intra- 
abdominal conditions  in  a  safe  and  effective  way.  Even  in  the  restricted  class 
of  cases  in  which  there  is  free  intraperitoneal  hemorrhage,  the  socalled 
"tragic"  cases,  it  is  probable  that  not  many  patients  really  die  at  once  from 
the  loss  of  blood.  There  are  some  that  do,  but  they  are  comparatively  few, 
as  indicated  by  mortuary  records  and  by  the  number  of  patients  that  come  to 
operation  later  with  a  history  of  having  passed  through  a  severe  attack  of 
intra-peritoneal  hemorrhage.   It  is  the  repeated  hemorrhages,  with  the  result- 


792  EXTRA-UTERINE  PREGNANCY 

ing  peritoneal  irritation  and  inflammation  coming  on  within  a  few  days  or  a 
few  weeks,  that  constitutes  the  greatest  menace  and  that  causes  the  deatli, 
rather  than  the  mere  withdrawal  of  a  certain  amount  of  blood  from  the  cir- 
culation at  the  primary  rupture.  This  being  the  case,  the  patient  has  a  better 
chance  of  surviving  the  primary  loss  of  blood  if  simply  kept  quiet  without 
operation,  than  if  operated  on  at  an  inopportune  time  or  without  reliable 
antiseptic  preparation,  or  by  a  person  without  adequate  experience  in  ab- 
dominal surgery. 

In  most  of  these  cases  the  hemorrhage  has  ceased  by  the  time  the  physi- 
cian reaches  the  patient.  Whether  this  is  the  case  can  be  determined  with 
a  fair  degree  of  certainty,  as  a  rule,  by  watching  the  patient  for  a  short 
time.  If  the  hemorrhage  has  ceased,  it  will  be  seen  that  the  pain  is  dimin- 
ishing and  the  pulse  getting  better.  If  it  is  decided  to  defer  operation  until 
the  patient  has  recovered  from  the  shock  and  the  acute  anemia,  the  patient 
must  be  kept  quiet  in  the  horizontal  posture  absolutely  and  should  make 
no  voluntary  movement;  no  sitting  up,  nor  moving  of  the  extremities  nor 
straining;  no  enemata  nor  purgatives.  If  she  is  to  be  moved  to  a  hospital, 
it  must  be  with  practically  no  more  disturbance  than  if  she  were  lying 
flat  in  bed.  For  the  first  48  hours  avoid  bowel  movement  if  possible  and 
give  very  little  food.  The  severe  thirst,  caused  by  the  blood  loss,  may 
be  relieved  by  small  doses  of  water,  and  by  saline  solution  per  rectum 
by  the  drop  method  (proctoclysis).  Pain  and  restlessness  are  to  be  relieved 
by  sedatives  hypodermically  or  by  mouth.  Guard  against  vomiting  and 
avoid  pelvic  examination,  for  either  is  very  likely  to  start  up  fresh  hem- 
orrhage. After  the  first  two  or  three  days  a  little  more  freedom  may  be 
allowed  as  regards  nourishment,  enemata  and  movement  of  arms  and  legs. 
But  the  patient  must  maintain  the  horizontal  posture  strictly.  The  patient 
must  be  especially  warned  against  straining  in  any  way  and  against  trying 
to  sit  up  a  little  because  she  feels  better.  An  attempt  at  sitting  up  in  bed 
may  undo  all  the  good  of  the  previous  rest,  as  shown  in  the  case  mentioned 
on  page  777.  Where  the  hemorrhage  has  been  very  severe  it  Avill  usually 
require  ten  days  to  two  weeks  for  the  patient  to  recuperate  sufficiently  to 
present  a  good  margin  of  reserve  force  for  the  operative  work.  With  a  less 
abundant  internal  hemorrhage  the  patient  may  be  in  good  condition  for 
operation  within  a  few  days. 

It  must  not  be  forgotten  that  in  these  cases  there  is  always  the  possibility 
of  the  hemorrhage  starting  up  again  suddenly,  in  spite  of  the  care  to  pre- 
vent it.  Consequently,  I  always  feel  better  if  the  patient  is  in  the  hospital 
while  waiting  for  her-  '"'deferred  operation."  Then,  if  renewed  hemorrhage 
develops,  operation  can  be  carried  out  promptly  before  the  patient  again 
passes  into  the  condition  of  extreme  collapse.  These  desperate  cases,  where 
the  vital  forces  are  at  a  low  ebb,  require  much  judgment  and  discrimination 
as  to  when  to  operate  in  a  particular  case  and  as  to  just  what  to  do  at  the 
operation — on  the  one  hand,  to  stop  the  bleeding  and  thus  prevent  the  patient 
from  passing  into  an  absolutely  hopeless  condition,  and,  on  the  other  hand, 


PELVIC  HEMORRHAGE  793 

to  avoid  snuffing  out  the  little  spark  of  life  remaining  by  the  added  strain 
of  intraperitoneal  manipulations  and  anesthesia.  The  anesthesia  and  oper- 
ative work  must  be  reduced  to  a  minimum,  both  in  duration  and  extent. 
Some  cases  can  be  satisfactorily  operated  on  under  local  anesthesia,  and 
occasionally  there  is  a  case  in  which  the  patient's  sensibilities  are  so  ob- 
tunded  that  practically  no  anesthesia  is  necessary  for  the  work  required. 

By  the  term  "local  anesthesia"  I  mean  a  true  local  anesthesia  (as  induced 
by  cocaine  or  eucaine,  or  some  similar  preparation)  and  not  general  anes- 
thesia by  hypodermic  injection.  I  Avould  warn  particularly  against  the  use 
of  seopolamin  (h3^oscin)  in  these  cases  where  the  depression  is  so  marked. 
The  induction  of  general  anesthesia  by  hypodermic  injection  of  this  drug  is 
not  the  simple  and  harmless  procedure  one  might  infer  from  the  tenor  of 
the  flood  of  advertising  literature  which  is  being  sent  out  by  a  certain  inter- 
ested commercial  house.  A  number  of  deaths  have  been  caused  by  the  use  of 
this  drug,  and  it  is  especially  dangerous  in  these  serious  conditions  with 
marked  depression.  When  necessary  to  give  something  to  relieve  pain  or 
produce  general  anesthesia  in  the  class  of  cases  under  consideration,  it  is 
better  to  use  some  reliable  drug  the  effect  of  which  is  uniform  and  can  be 
accurately  gauged  and  depended  upon — such  as  morphine  hypodermatically 
or  ether  by  inhalation. 

5.  Pelvic  Hematoma  (Fig.  668).  If  there  are  any  evidences  of  active  or 
recurring  hemorrhage,  the  preferable  treatment  is  abdominal  section,  with 
removal  of  the  damaged  tube  and  the  blood-mass.  If  there  is  simply  a 
quiescent  blood-collection  in  the  connective  tissue,  keep  the  patient  quiet  and 
watch.  If  the  blood-mass  is  gradually  absorbed,  keep  the  patient  quiet  till 
the  mass  has  largely  disappeared,  and  then  she  may  be  allowed  up  and  be 
counted  practically  well.  If  the  mass  remains  stationary  and  symptoms  of 
pronounced  irritation  persist  or  arise  later,  the  patient  should  be  subjected 
to  operation — abdominal  or  vaginal,  as  indicated  by  the  location  of  the  mass 
and  the  accompanying  symptoms. 

6.  Advanced  Oases.  These  cases  vary  so  much  that  it  is  impossible  to  give  a 
rule  applicable  to  all. 

In  some  of  them  immediate  operation  is  indicated,  while  in  others  it  is 
advisable  to  wait  for  a  time,  either  because  the  child  has  only  recently  died 
and  the  placenta  and  adhesions  are  still  dangerously  vascular,  or,  in  rare 
cases,  because  there  is  good  reason  to  hope  for  saving  the  child  alive  without 
"unjustifiable  risk  to  the  mother  (Fig.  669). 

OTHER  PELVIC  DISORDERS. 

Hemorrhage. 

When  there  is  hemorrhage  into  the  pelvis  from  any  cause,  if  the  blood 
passes  into  the  peritoneal  cavity,  it  is  known  as  "intraperitoneal  hemor- 
rhage." If  the  amount  of  blood  is  small  and  becomes  shut  in  the  pelvic 
cavity  by  a  roof  of  exudate  and  adhesions  above,  it  is  referred  to  as  a  "pelvic 


794  OTHER  PELVIC  DISORDERS 

hematocele."  If  the  blood,  instead  of  passing  into  the  peritoneal  cavity, 
passes  into  the  connective  tissue,  the  resulting  condition  is  called  "pelvic 
hematoma. ' ' 

The  usual  cause  of  blood  in  the  pelvis  is  extrauterine  pregnancy,  the  char- 
acteristics of  which  have  just  been  presented. 

Hemorrhage  into  the  pelvis  occasionally  occurs,  however,  from  other 
causes.  A  collection  of  blood  in  the  pelvis,  either  in  the  pelvic  peritoneal 
cavity  or  in  the  connective  tissue,  may  be  caused  by  any  one  of  the  following 
conditions : 

1.  Rupture  of  a  varicose  vein  of  the  broad  ligament. 

2.  Hemorrhage  from  a  Fallopian  tube,  due  to  inflammation  or  to  a  polypus, 
or  some  other  tumor  of  the  tube  (page  796). 

3.  Hemorrhage  from  an  ovary,  due  to  acute  congestion  or  inflammation, 
or  to  a  papillary  growth  (page  818). 

4.  Rupture  of  one  of  the  dilated  vessels  on  a  large  tumor. 

5.  Hemorrhage  from  injury  due  to  a  blow  or  fall. 

6.  Hemorrhage  from  injury  due  to  forcible  reposition  of  an  adherent 
uterus. 

The  diagnosis  is  made  by  the  same  symptoms  that  indicate  hemorrhage  in 
extrauterine  pregnancy,  but  without  the  evidences  of  pregnancy. 

As  in  the  vast  majority  of  cases  of  spontaneous  pelvic  hemorrhage  the 
cause  is  extrauterine  pregnancy,  this  affection  must  be  excluded  in  any  par- 
ticular case  before  any  other  diagnosis  is  permissible.  Sometimes  this  may  be 
excluded  by  the  circumstances  of  the  case — for  example,  the  patient  may  be 
a  virgin,  or  may  be  past  the  menopause,  or  may  have  had  no  recent  oppor- 
tunity of  becoming  pregnant.  In  some  cases  the  differential  diagnosis  can 
not  be  made  until  the  operation,  when  one  of  the  causes  above  mentioned  may 
be  apparent,  with  absence  of  indications  of  tubal  pregnancy.  In  a  doubtful 
case  the  diagnosis  should  be  reserved  until  the  suspicious  mass,  removed  at 
operation,  has  been  submitted  to  microscopic  examination.  In  a  tubal  preg- 
nancy, ruptured  early  and  not  operated  on  for  several  weeks,  all  naked  eye 
evidence  of  the  pregnancy  may  disappear.  But  by  microscopic  examination 
of  the  affected  tube,  evidence  of  the  pregnancy  may  be  found. 

The  treatment  of  pelvic  hemorrhage  not  due  to  tubal  pregnancy  depends 
on  the  circumstances  of  the  case.  If  the  hemorrhage  is  into  the  connective 
tissue  (hematoma)  and  well  circumscribed,  palliative  treatment  only  is  indi- 
cated. This  consists  of  perfect  quiet  in  the  recumbent  position,  elevation  of 
the  foot  of  the  bed  and  an  ice-bag  over  the  abdomen,  and  sedatives  sufficient 
to  give  rest.  In  intraperitoneal  hemorrhage  of  slight  extent,  where  tubal 
pregnancy  can  be  excluded,  the  same  treatment  is  indicated.  In  either  ease 
the  effused  blood  may  be  largely  absorbed.  If  after  a  time  it  still  remains  and 
gives  trouble  or  suppurates,  the  hematoma  or  hematocele,  as  the  case  may  be, 
may  be  opened  from  the  vagina,  emptied  and  packed  with  gauze,  the. same 
as  a  pelvic  abscess. 

If  there  is  serious  intraperitoneal  hemorrhage,  it  requires  abdominal  sec- 


FULMINATING  PELVIC  EDEMA  795 

tion  if  the  patient  is  in  fit  condition,  the  additional  steps  in  the  intra-al)domi- 
nal  treatment  depending  upon  the  conditions  found  within  the  abdomen. 

Fulminating  Pelvic  Edema. 

Fulminating  pelvic  edema  is  the  term  applied  to  an  intense  and  wide- 
spread edema  of  the  pelvic  interior,  that  comes  on  suddenly  without  appar- 
ent adequate  cause.  It  is  accompanied  with  serious  symptoms  and  usually 
with  extreme  prostration.  In  fact,  the  sudden  onset,  the  severity  of  the 
symptoms  and  the  marked  collapse  suggest  ruptured  tubal  pregnancy,  and 
this  mistaken  diagnosis  has  been  made  in  some  of  the  cases.  It  is  a  rare  con- 
dition and  presents  a  puzzling  problem  in  etiology  and  in  diagnosis.  Llost 
of  the  cases  have  been  associated  with  chronic  inflammatory  lesions  in  the 
pelvis,  but  why  the  sudden  edema  and  serious  symptoms  should  develop 
without  apparent  cause  has  not  been  satisfactorily  explained.  Clinically, 
however,  the  condition  must  be  recognized  and  treated;  hence  its  inclusion 
here. 

The  salient  features  in  the  pathology,  symptomatology  and  treatment  of 
this  rare  affection  can  best  be  presented  by  detailing  some  typical  cases. 

Fulminating  Pelvic  Edema. — Last  year  I  was  called  in  consultation  by  Dr.  S.  T.  Bas- 
sett,  of  St.  Louis,  to  see  a  patient  with  pelvic  disturbance.  It  was  Sunday;  the  patient 
had  attended  church  in  the  morning  feeling  fairly  well,  but  while  there  became  very 
sick  and  could  scarcely  get  home.  She  had  a  chill,  followed  by  severe  headache  and 
general  aching,  but  no  localizing  symptoms.  There  was  no  apparent  local  trouble  in 
any  part  of  the  body  to  account  for  the  fever,  which  rose  to  105.5°.  By  evening  there 
was  evidence  that  the  pelvis  was  the  seat  of  the  disturbance  and  I  was  asked  to  see 
the  patient. 

Examination. — I  saw  her  about  10  p.  m.  The  temperature  had  been  reduced  to  104°. 
The  pulse  was  rapid,  but  of  fair  volume.  The  pelvis  was  filled  with  a  tender  mass  which 
surrounded  the  uterus  and  fixed  it  firmly.  There  seemed  to  be  acute  pelvic  inflamma- 
tion with  extensive  exudate.  But  there  was  no  apparent  cause,  either  recent  or  remote. 
The  patient  had  always  been  rather  nervous  and  this  had  been  somewhat  worse  of 
late,  but  there  had  been  no  symptoms  indicating  pelvic  disease  of  any  kind.  The  next 
day  the  temperature  was  104.2°,  pulse  120,  respiration  28,  and  there  was  much  peri- 
toneal irritation.  Operation  at  once  was  indicated,  to  check  the  rapidly  progressing 
inflammation,  if  possible,  and  accordingly  the  patient  was  taken  to  the  hospital. 

Operation. — When  the  abdomen  was  opened  the  pelvis  was  found  filled  with  small 
encysted  collections  of  fluid  involving  the  tubes,  ovaries,  broad  ligament  and  uterus. 
The  cysts  or  pseudocysts  were  of  various  sizes,  were  filled  with  clear  serum  and  seemed 
to  extend  deeply  into  the  substance  of  the  organs  involved.  From  the  appearance  I  sus- 
pected hydatid  disease.  I  removed  all  the  cysts  that  it  was  feasible  to  remove  and 
then  drained  the  pelvis  through  the  abdominal  incision. 

The  temperature  dropped  within  a  few  hours  to  98°,  and  it  did  not  again  go  high. 
During  the  first  part  of  the  period  of  convalescence  it  ranged  from  99°  to  100.2°,  and 
later  dropped  to  normal,  where  it  remained.  The  wound  and  drainage  tract  healed 
rapidly  and  the  patient  had  a  smooth  convalescence.  Laboratory  examination  of  the 
tissues  removed  showed  no  bacteria  of  any  kind,  no  evidence  of  hydatid  disease,  and 
no  specific  pathologic  process  that  would  adequately  account  for  the  alarming  symp- 
toms and  the  marked  tissue  change. 

Fulminating    Pelvic    Edema.— Reported   by   Briggs.    A  married   woman,   whose    men- 


796  OTHER  PELVIC  DISORDERS 

struation  had  been  normal,  came  complaining  of  malaria  and  some  pelvic  pain.  Pelvic 
examination  showed  nothing  abnormal  except  a  slight  fullness  about  the  left  adnexa. 
Two  days  later  the  patient  returned  to  the  office,  very  sick.  Her  face  was  pale  and 
pinched  and  anxious;  pulse  120,  small  and  weak;  temperature,  100°.  The  pelvis  was 
then  completely  filled  with  a  fluctuating  mass.  The  rapid  development  of  the  mass, 
with  almost  no  fever,  pointed  to  hemorrhage  as  the  cause,  and  a  diagnosis  of  tubal 
pregnancy  was  made.  At  the  operation  the  pelvis  was  found  filled  with  small  cysts  of 
various  sizes,  formed  by  collections  of  serum  within  the  connective  tissue.  There  was 
no  tubal  pregnancy.    The  pelvis  was  drained  and  the  patient  recovered. 

Fulminating  Pelvic  Edema. — Reported  by  Briggs.  Patient's  menstruation  was  de- 
layed four  days,  then  came  on  scanty  and  was  accompanied  by  paroxysmal  pains, 
which  caused  the  patient  to  think  she  was  having  a  miscarriage.  After  some  days  the 
pain  became  more  severe  and  the  patient  had  two  fainting  spells.  Temperature  was 
normal,  pulse  90  and  small  and  compressible.  The  abdomen  was  sensitive.  Sedatives 
were  given,  which  diminished  the  pain,  but  the  shock  increased.  The  radial  pulse  be- 
came imperceptible  and  the  skin  and  mucous  membranes  were  markedly  anemic.  The 
uterus  was  enlarged,  retroverted,  fixed  and  sensitive,  adnexa  not  felt.  Liquid  could  be 
demonstrated  in  the  flanks.    Diagnosis,  tubal  pregnancy  with  rupture. 

Operation. — The  pelvis  and  lower  abdomen  were  filled  with  great  blebs  due  to  the 
collection  of  serum  in  the  connective  tissue,  causing  the  peritoneum  to  pouch  into  the 
pelvis  from  all  directions.  Both  tubes  were  chronically  infiamed  and  the  right  ovary 
was  enlarged  and  cystic. 

The  patient's  condition  continued  bad  and  she  died  some  hours  after  the  operation. 
The  feature  of  the  case  was  the  enormous  amount  of  serum  pocketed  in  the  connective 
tissue,  without  any  evidence  of  recent  infiammation. 

Fulminating  Pelvic  Edema. — Reported  by  Legueu.  Shortly  after  a  normal  menstrua- 
tion, patient  was  suddently  attacked  with  violent  pelvic  pain  accompanied  by  syncope, 
extreme  pallor  and  cold  extremities.  The  abdomen  was  distended,  hard  and  painful 
to  pressure.  Vaginal  examination  disclosed  a  fiuctuating  mass  in  the  cul-de-sac.  Diag- 
nosis, retrouterine  hematocele.  On  opening  the  abdomen  a  quantity  of  yellow  serum 
escaped.  There  were  large  collections  of  serum  in  the  tissues  about  the  right  adnexa, 
aggregating  a  pint.  The  patient  recovered.  Examination  of  the  serum  showed  only 
leucocytes  and  peritoneal  cells. 

Fulminating  Pelvic  Edema. — Reported  by  Jocet.  Patient,  aged  28,  married  eight 
years,  no  children,  had,  on  three  separate  occasions,  an  attack  of  severe  abdominal 
pain  accompanied  by  an  accumulation  of  fiuid  in  the  right  iliac  fossa,  which  presented 
the  characteristics  of  hematocele.  Twice  the  mass  terminated  by  resolution  and  the 
patient  was  perfectly  well  in  the  intervals.  The  third  time,  after  the  usual  symptoms 
of  the  supposed  hematocele  had  continued  some  weeks  with  improvement,  the  patient 
was  suddenly  seized  with  violent  abdominal  pain,  accompanied  by  pallor,  anxious  facies 
and  incessant  vomiting.  The  mass  enlarged  and  there  developed  features  that  pointed 
to  inflammation  rather  than  hemorrhage  as  the  cause  of  the  trouble.  Operation  showed 
the  pelvis  filled  with  encysted  collections  of  serum,  and  finally,  deep  in  the  pelvis, 
there  was  found  an  old  ovarian  abscess,  which  was  evidently  the  exciting  cause  of 
the  surrounding  edema. 

Tumors  of  Fallopian  Tubes. 

Primary  tumors  of  the  Fallopian  tubes  are  very  rare.  Fibromyoma,  car- 
cinoma, and  sarcoma  may  occur  here,  and  they  present  the  same  structure 
and  tendencies  as  elsewhere. 

If  arising  from  the  interstitial  portion  of  the  tube,  they  produce  the-  symp- 
toms of  similar  tumors  of  the  uterus.  If  arising  from  the  outer  portion  of  the 
tube,  they  correspond  in  position  to  tumors  of  the  ovary. 


VARIOUS  VEINS  IN  PELVIS 


797 


It  is  interesting  to  note  that  chorio-epithelioma  has  been  found  in  a  tube  fol- 
lowing tubal  pregnancy. 

The  diagnosis  of  tumors  of  the  tube  is  usually  made  after  the  abdomen  is 
opened.  They  present  no  definite  distinguishing  characteristics,  and  when 
felt  in  examination  are  usually  taken  for  growths  arising  from  those  struc- 
tures in  which  tumors  more  frequently  occur — namely,  the  uterus,  the  ovary 
or  the  broad  ligament. 

The  treatment  of  tumors  of  the  tube  is  the  same  as  for  like  growths  in 
other  pelvic  organs. 

Varicose  Veins  of  Broad  Ligament. 

Occasionally  the  Veins  of  the  broad  ligament  are  found  markedly  dilated, 
and  in  the  dilated  veins  are  sometimes  found  thrombi  and  even  small  stones 
(phleboliths). 

The  principal  etiologic  factors  which  have  been  mentioned  are  subinvolu- 
tion of  the  broad  ligaments  following  pregnancy,  relaxation  of  the  tissues 


Fig.  670.     Ligating  Varicose  Veins  in  the  Broad  Ligament.     (Reed — Text-hook  of  Gynecology.) 

from  poor  general  health,  and  obstruction  of  the  venous  circulation  of  the 
broad  ligament  by  tumors,  or  by  heart  disease,  or  by  loaded  bowel,  or  by 
uterine  displacement. 

The  symptoms  (weight  and  pressure  when  upright  and  relieved  by  the  re- 
cumbent posture)  are  not  distinctive — in  fact,  the  condition  is  usually  over- 
shadowed by  more  evident  lesions.  In  most  cases  so  far  reported  this  con- 
dition was  thought  of  only  after  the  abdomen  was  open  and  the  enlarged 
veins  apparent. 

In  cases  of  persistent  pelvic  pain  without  palpable  lesion,  this  condition 
should  be  thought  of,  and  if  the  symptoms  are  severe  in  spite  of  palliative 
measures  it  may  be  advisable  to  make  an  exploratory  abdominal  section, 
with  the  idea  of  correcting  this  condition  if  found. 

When  phleboliths  or  thrombi  (Fig.  406)  are  present,  they  may  in  excep- 
tional cases  form  masses  that  can  be  felt  on  bimanual  palpation. 

The  treatment  is  abdominal  section  and  ligation  of  the  enlarged  veins  at 
short  intervals,  as  advocated  by  Reed  (Fig.  670),  and  free  incision  and  evacu- 
ation of  the  ligated  portions. 


798  OTHER  PELVIC  DISORDERS 

Echinococcus  Disease  of  Pelvis. 

Ecliinococeus  disease  is  occasionally  found  in  the  pelvis.  For  a  descrip- 
tion of  this  affection  see  echinococcus  disease  of  the  uterus  (page  593).  When 
it  affects  other  pelvic  structures,  it  is  supposed  in  most  cases  to  come  from  the 
rectum  by  way  of  the  perirectal  connective  tissue. 

Pseudo-tuberculosis  of  Peritoneum. 

This  is  a  rare  condition,  in  which  the  pelvic  peritoneum  is  studded  with 
small  opaque,  thickened  spots,  presenting  the  superficial  appearance  of  peri- 
toneal tuberculosis.  Microscopic  examination  of  the  involved  tissue,  however, 
shows  no  tuberculosis,  but  simply  chronic  inflammatory  infiltration. 


799 


CHAPTER   XII. 

TUMORS  OF  THE  OVARY  AND  PAROVARIUM. 

Before  taking  up  the  tumors  of  the  ovary  and  parovarium  I  wish  to  call 
attention  to  certain  points  in  the  anatomy  and  physiology  of  the  structures 
involved. 

POINTS  IN  ANATOMY  AND  PHYSIOLOGY. 

THE  OVARY. 

The  ovaries  are  situated  one  on  either  side  of  the  uterus  near  the  pelvic 
brim  and  close  to  the  outer  end  of  the  Fallopian  tube  (Fig.  3,  4).  Each  ovary 
projects  from  the  posterior  wall  of  the  broad  ligament  of  its  respective  side 
and  the  peritoneal  fold  thus  formed  is  called  the  "mesovarium"   (Fig  671). 


Fig.  671.  Vertical  Section  through  the 
Broad  Ligament,  showing  the  R,eIation  of 
the  Ovary  to  the  same,.  5,  Fallopian  tube. 
6,  Round  ligament.  7,  Ovary.  7',  Meso- 
varium,  connecting  the  ovary  with  the 
broad  ligament.      (Jewett,  from  Testut — 

ractice  of  Obstetrics.) 


Fig.  672.  Section  of  the  Ovary  of  a  Cat.  1,  Peritoneal 
surface  of  the  ovary.  1,  Hilum.  2,  Medullary  portion  ol 
ovary.  3,  Cortical  portion.  5,  Small  Graafian  follicles. 
7,  8,  9,  Maturing  Graafian  follicles.  10,  Corpus  luteum. 
(Jewett,  after  Schoen — Practice  of  Obstetrics.) 


800  TUMORS  OF  THE  OVARY  AND  PAROVARIUM 

It  is  through  this  attachment  to  the  broad  ligament  that  the  ovary  receives 
its  blood  supply,  this  being  the  point  where  the  vessels  enter. 

The  shape  of  the  ovary  is  much  like  that  of  an  almond.  In  size  the  ovaries 
vary  much  in  different  individuals,  and  even  in  the  same  individual  the  two 
ovaries  may  differ  in  size.  Ordinarily  the  ovary  is  II/2  to  2  inches  in  length, 
about  1  inch  in  width,  and  about  %  inch  in  thickness.  It  weighs  75  to  150 
grains. 

Structure.  In  structure  the  ovary  is  simply  a  bunch  of  ova,  or  microscopic 
eggs,  supported  and  held  together  by  the  connective  tissue  which  forms  the 

Trex.  Tint.  D..  WQ, 


^^=^^^S.^^\ 


1  ;  ^ 


>,  / 


^ .  ^^  I, 


Fig.  073.     A  Graafian  Follicle  with  its  Contained  Ovum,  highly  magnified.     M.  G.,  membruua  mamilosa. 
The  ovarian  stroma  is  also  well  shown.     (Williams — Obstetrics.) 

frame-work.  Each  ovum  is  contained  within  a  minute  sac,  called  the  ovisac 
or  Graafian  follicle  (Fig.  672)-.  The  connective  extends  between  the  follicles 
in  all  directions,  and,'  in  addition  to  supporting  and  protecting  them,  it  car- 
ries the  blood  vessels  that  nourish  them  and  also  the  lymph  vessels  and 
nerves.  This  connective  tissue  constitutes  the  ovarian  stroma  and  is  j:)eculiar 
in  that  it  is  exceedingly  rich  in  cells.  These  are  spindle-shaped  connective 
tissue  cells,  and  they  are  packed  so  closely  together  that  in  an  ordinary 
microscopic  preparation  the  tissue  seems  to  be  made  up  exclusively  of  long, 
oval  nuclei  lying  close  together  (Fig.  673).    Near  the  peripliery  of  the  ovary 


POINTS  IN  ANATOMY 


801 


the  connective  tissue  fibers  become  more  numerous  and  the  nuclei  fewer,  so 
that  there  is  here  a  rather  dense  capsule.  This  tibrous  capsule  of  the  ovary  is 
known  as  the  "tunica  albuginea. "  It  is  simply  a  condensation  of  the  ovarian 
stroma  and  serves  to  protect  the  deeper  structures  of  the  ovary.  Outside  of 
this  fibrous  layer  lies  the  epithelial  covering. 

That  portion  of  the  ovary  at  which  the  vessels  find  entrance  and  exit  is 
called  the  hilum  (Fig.  672).  Immediately  about  the  hilum,  and  extending 
some  little  distance  into  the  ovary,  is  the  area  known  as  the  medulla  or 
medullary  portion.  This  is  occupied  by  the  blood  vessels,  lymph  vessels,  the 
nerves  and  supporting  connective  tissue.   It  contains  no  follicles. 


Fig.  674.  Development  of  the  Ovary  (after  Wiedersheim).  A,  an  ingrowth  of  the  germinal  epithehum, 
forming  a  cell-cord,  which  breaks  up  into  primitive  Graafian  follicles;  B,  a  primitive  Graaflan  follicle,  with  its 
contained  primitive  ovum;  C,  D,  E,  later  stages  in  the  development  of  the  Graafian  follicle. 


The  remaining  part  of  the  ovary  contains  the  Graafian  follicles,  and  is 
called  the  cortex  or  cortical  portion  (Fig.  672).  The  free  surface  of  the  cor- 
tical portion — that  is,  the  peritoneal  surface  of  the  ovary — is  covered  with 
aylindrical  epithelium,  the  remains  of  the  germinal  epithelium,  from  which 
the  ova  and  Graafian  follicles  were  formed  by  infoldings  (Fig.  674). 

The  Graafian  follicles  are  very  numerous  and  of  different  sizes.  The  small 
young  follicles  lie  near  the  surface  and  number  thousands.  They  are  about 
1/100  of  an  inch  in  diameter.  The  larger,  older  follicles  lie  deeper  and  are 
not  so  numerous.   The  largest  of  these  measure  1/25  of  an  inch  in  diameter. 

The  Graafian  follicle  is  lined  with  an  epithelial  layer  several  cells  thick, 


802 


TUMORS  OF  THE  OVARY  AND  PAROVARIUM 


called  the  "membrana  granulosa,"  and  is  filled  with  clear  viscid  flnid,  the 
"liquor  foUiculi. "  The  ovum  lies  within  the  follicle  near  one  side  and  is 
completely  surrounded  by  cells  of  the  membrana  granulosa   (Fig.  673). 


Fig.  675.  A  Corpus  Luteum,  fifteen  daj's 
from  the  beginning  of  menstruation. 
(Baldy — American  Text-book  of  Gynecology.) 


Fig.  676.  Ovary  of  a  Virgin,  shomng  an 
unusually  large  corpus  luteum.  Notice  what 
a  large  part  of  the  ovary  the  corpus  luteum 
occupies.  (Piersol,  after  Hirst — American 
Text-book  of  Obstetrics.) 


As  the  Graafian  follicle  matures,  it  again  approaches  the  surface  and  be- 
comes still  larger.  It  gradually  protrudes  at  the  free  surface  of  the  ovary 
and  when  ripe  it  bursts,  liberating  the  ovum  on  the  surface  of  the  ovary,  from 
where  it  finds  its  way  into  the  Fallopian  tube.    This  ripening  and  bursting  of 


Fig.  677.     Section  of  a  Corpus  Luteum,  showing  the  wavy  line  composed  of  lutein  cells.     (Williams— 
Obstetrics.) 


POINTS  IN  ANATOMY 


803 


the  Graafian  follicle  and  liberation  of  the  contained  ovum  is  called  "ovula- 
tion," and  is  usually  coincident  with  menstruation. 

After  the  ripened  ovum  is  discharged,  the  ruptured  follicle  fills  with  bloody 
serum,  which  clots.  The  rent  in  the  follicular  wall  soon  heals  and  the  blood 
clot  becomes  partially  decolorized.  Tliis  follicle,  filled  with  blood  clot,  is  very 
prominent  (Figs.  675,  676)  and  when  encountered  during  tlie  course  of  an 
operation  has  been  mistaken  for  hematoma  of  the  ovar}',  though  it  is  simply 
a  recently  ruptured  follicle  and  consequently  a  normal  structure. 

In  a  few  days  there  appear  certain  peculiar  cells  containing  pigment.  These 
cells  are  large,  reseml^ling  decidua  cells.  They  are  formed  first  about  the 
periphery  of  the  -fibrinous  mass,  but  they  gradually  increase  in  number  and 
advance  toward  the  center,  until  finally  they  fill  nearly  the  wiiole  interior 


Fig.  678.  The  Wavy  Line  in  the  Wall  of  the 
Corpus  Luteum,  highly  magnified  to  show  the 
lutein  cells.     (Williams — Obstetrics.) 


Fi,  G/9  The  Corp  IS  Albicans  -Vfter  the  rup- 
tured follicle  has  passed  through  the  various 
stages  of  the  corpus  luteum,  there  remains  simply 
a  wavy  line  of  fibrous  tissue,  representing  the  final 
stage  of  the  ruptured  follicle.  The  retraction  of 
this  scar-tissue  causes  depressions,  as  shown  in 
Fig.  680.     (Williams— 06.s<e<ric.s.) 


of  the  broken  follicle  (Figs..  677,  678).  The  pigment  in  the  cells  is  yellow; 
consequently  they  are  called  "lutein"  cells,  and  the  mass  formed  by  them  is  of 
course  also  yellow  and  hence  is  called  the  corpus  luteum  (yellow  body).  A 
section  of  a  corpus  luteum  shows  a  wavy  yellow  outer  portion  formed  by  the 
lutein  cells  (Fig.  676).  The  source  of  these  lutein  cells  is  still  in  dispute. 
Some  authorities  hold  that  they  are  derived  from  the  remnants  of  the  mem- 
brana  granulosa,  while  others  state  that  they  are  derived  from  the  connec- 
tive tissue  cells  of  the  "theca  interna"  (the  internal  layer  of  the  fibrous 
capsule  of  the  Graafian  follicle). 

The  lutein  cells  gradually  disappear  and  after  a  time  the  area  of  the 
ruptured  follicle  is  occupied  only  by  scar  tissue  (Fig.  679).  The  area  is  then 
no  longer  yellow,  but  W'hite,  and  consequently  is  called  the  corpus  albicans 
(w^hite  body).     The  corpus  albicans,  consisting  of  scar  tissue,  represents  the 


804 


TUMORS  OF  THE  OVARY  AND  PAROVARIUM 


final  stage  of  the  ruptured  follicle.  After  many  follicles  have  ruptured,  the 
surface  of  the  ovary  often  becomes  very  uneven  on  account  of  the  number  of 
these  depressed  scars   (Fig.  680). 

Ordinarily  the  corpus  luteum  passes  through  the  changes  described  in  a 
short  time.  If,  however,  pregnancy  follows  ovulation,  the  corpus  lutem  of 
that  ovulation  grows  very  large  and  remains  for  months  before  retrograde 
changes  set  in. 

Ligaments.  The  ovary  lies  in  the  pelvis  obliquely  and  its  inner  end  is 
about  one  inch  from  the  uterus.  Extending  from  this  end  of  the  ovary  to  the 
uterus  is  a  small  fibro-muscular  cord,  the  "utero-ovarian  ligament,"  which 
joins  the  uterus  just  below  the  Fallopian  tube  (Fig.  4).    The  suspensory  liga- 


Fig.  680.  The  Ovary  of  a  Woman  Twenty- 
three  Years  of  Age.  Notice  the  depressed  scars, 
resulting  from  ruptured  follicles  (Piersol,  after 
Sutton — American  Text-book  of  Obstetrics.) 


Duct  of 
Muellef 

Parovarian 

■remains 
Parovarium 

(EeoopMron) 


-  ParoophQron 


Duct  of 

Muellef 


.  -    Uterus 
~-   Duct  of 

Gartner 

Fig.  681.  Embryonic  Genital  Organs,  showing 
the  parovarium  and  paroophoron,  and  their  re- 
lation to  the  tube  and  ovary  and  duct  of  Gartner. 
(Abel,  after  KoUmann- — Gynecological  Pathology.) 


ment  of  the  ovary,  the  "ligamentum  suspensorium  ovarii,"  is  the  thickened 
edge  of  the  broad  ligament  connecting  the  ovary  and  tube  with  the  side  of 
the  pelvis.  The  "infundibulo-ovarian  ligament"  extends  from  the  ovary  to 
the  outer  end  of  the  Fallopian  tube. 

Vessels  and  Nerves.  The  ovary  is  supplied  with  blood  by  several  branches 
of  the  ovarian  artery,  which  corresponds  to  tlie  spermatic  artery  in  the  male. 
The  ovarian  artery  arises  directly  from  the  abdominal  aorta  and,  passing 
downward  to  the  side  of  the  pelvis,  enters  the  broad  ligament  and  sends 
branches  to  the  ovary  and  uterus  and  tube.  The  veins  correspond  to  the 
artery  and  form  a  plexus  near  the  hilum,  which  is  known  as  the  pampiniform 
plexus,  sometimes  called  the  ovarian  plexus. 


POINTS  IN  PHYSIOLOGY  805 

The  lymphatic  spaces  siirronnd  the  Graafian  follicles  and  ramify  through- 
out the  connective  tissue  of  the  ovary.  They  pass  out  at  the  hilum  and 
anastomose  "with  the  uterine  lymphatics  in  the  broad  ligament  and  empty 
into  the  lumber  glands. 

The  nerves  come  from  the  renal  and  spermatic  ganglia.  The  fibers  pass 
along  in  the  connective  tissue  framework  to  all  the  Graafian  follicles  and 
terminate  in  the  follicular  epithelium. 

Physiology  of  the  Ovary. 

The  principal  function  of  the  ovary  is  the  formation  of  ova  and  the  prepara- 
tion of  the  same  for  impregnation.  The  ova  are  developed  from  primitive 
ova  derived  from  the  "germinal  epithelium"  of  the  embryo.  In  the  formation 
of  the  ovary  in  the  growing  embryo,  portions  of  the  germinal  epithelium  are 
included  within  the  organ,  and  from  these  included  cells  the  ova  and  Graafian 
follicles  are  developed  (Fig.  674).  A  remnant  of  the  primary  germ-epithelium 
remains,  as  the  layer  of  cylindrical  epithelium  covering  the  peritoneal  surface 
of  the  ovary.  In  the  preparation  of  ova,  nature  displays  a  lavish  hand.  It  is 
estimated  that  each  ovary  at  the  age  of  eighteen  years  contains  36,000  ova,  but 
not  more  than  200  of  these  reach  maturity. 

The  ovum,  which  is  the  most  important  structure  in  the  ovary,  is  a  single 
cell  composed  of  four  parts,  as  follows : 

a.  A  thick  surrounding  substance    or  membrane    called  the  "zona 
radiata"  or  zona  pellucida. 

b.  The  cell  substance  or  protoplasm,  the  inner  portion  of  which  is 
known  as  the  "vitellus." 

c.  The  nucleus  or  "germinal  vesicle." 

d.  The  nucleolus  or  ' '  germinal  spot. ' ' 

The  ovum  is  spherical,  and  when  fully  developed  measures  1-120  of  an  inch 
in  diameter.  Just  before  the  o\aim  is  discharged  upon  the  surface  of  the 
ovary  by  the  bursting  of  the  follicle,  as  previously  described,  it  goes  through 
a  process  of  ripening.  This  process  is  called  "maturation"  and  consists  in 
the  karyokinetic  division  of  the  nucleus  and  the  expulsion  of  a  small  portion 
of  it.  This  occurs  twice  in  succession.  The  cast  off  portions  have  been 
named  "polar  bodies."  The  polar  bodies  are  apparently  of  no  further  use, 
as  they  soon  disappear.  It  may  be  remarked  here  that  certain  tumors 
(teratomata)  are  supposed  to  originate  from  these  polar  bodies.  The  remains 
of  the  nucleus  wanders  to  near  the  center  of  the  cell  and  the  ovum  assumes 
a  resting  state.  It  is  then  ready  for  impregnation.  It  is  carried  into  the 
Fallopian  tube,  and,  if  impregnation  does  not  take  place,  passes  into  the 
uterus  and  out  of  that  organ  into  the  vagina  and  is  lost. 

In  recent  years  it  has  come  to  be  recognized  that  the  ovary  has  another 
function,  entirely  distinct  from  ovulation.  This  is  known  as  the  trophic  func- 
tion or  nutritional  function  of  the  ovary.  By  clinical  observations  and  by 
experiments  on  animals  the  following  facts  have  been  established. 


806  TUMORS  OF  THE  OVARY  AND  PAROVARIUM 

1.  That  the  ovary  controls  menstruation.  AYhen  the  ovaries  are  removed, 
menstruation  soon  ceases.  The  ovary  furnishes  the  "menstrual  impulse," 
though  the  menstrual  blood  itself  comes  from  the  uterus. 

2.  That  the  ovary  controls  the  development  of  the  uterus  and  of  the 
breasts.  "When  the  ovaries  of  newlj^-born  guinea  pigs  were  removed,  the 
breasts  and  the  uterus  and  even  the  external  genitals  failed  to  develop.  When 
one  ovary  was  left,  the  normal  development  took  place  the  same  as  though 
both  ovaries  were  present.  Similar  experiments  on  rabbits  and  on  dogs 
gave  similar  results — i.  e.,  the  removal  of  both  ovaries  in  the  young  prevented 
proper  development  of  the  uterus  and  the  breasts. 

3.  That  the  ovary  controls  to  a  considerable  extent  the  nutrition  of  the 
uterus,  even  in  the  adult.  Numerous  experiments  in  rabbits  and  dogs  and 
cows  have  shown  that  after  the  removal  of  both  ovaries  the  uterus  slowly 
atrophies  and  develops  the  characteristics  of  senility.  Clinical  experience 
and  pathological  investigation  have  shown  that  the  same  results  slowly  take 
place  in  women  after  the  removal  of  both  ovaries. 

4.  That  the  ovary  exercises  a  decided  influence  on  the  nervous  system.  In 
nearly  every  case  after  the  complete  removal  of  the  ovaries  there  appear  cer- 
tain nervous  disturbances.  These  are  practically  the  same  as  are  found 
accompanying  the  natural  menopause — hot  flashes,  fleeting  emotional  dis- 
turbances and  other  evidences  of  an  unstable  or  irritable  nervous  system. 
These  occur  so  regularly  after  double  oophorectomy  that  we  expect  them, 
and  give  to  the  symptom  group  the  name  "artificial  menopause"  or  induced 
menopause.  These  symptoms  usually  subside  after  one  or  two  or  three  years, 
as  in  the  natural  menopause.  Occasionally,  however,  they  persist  and  in- 
crease and  become  serious.  If  one  ovary  be  left,  or  even  part  of  an  ovary 
that  continues  to  fiuictionate,  these  symptoms  do  not  appear,  showing  that 
the  ovary  exercises  the  controlling  influence.  If  still  stronger  proof  of  this 
fact  be  desired,  it  is  found  in  this :  In  patients  suffering  with  these  trouble- 
some symptoms  folloAving  removal  of  both  ovaries,  healthy  ovaries  have  been 
transplanted,  with  the  result  that  the  symptoms  under  consideration  entirely 
disappeared. 

Now  comes  the  ciuestion,  how  does  the  ovary  exercise  this  marked  trophic 
influence,  evidenced  (1)  by  controlling  menstruation,  (2)  by  controlling  the 
development  of  the  uterus  and  breasts,  (3)  by  controlling  the  nutrition  of 
the  uterus  and  (4)  by  controlling  certain  nervous  disturbances?  It  was  for 
a  long  time  supposed  that  the  influence  was  reflex,  by  way  of  the  nerves 
in  the  ovary.  But  it  is  now  pretty  well  established  tliat  it  is  not  by  the  nerves, 
but  by  some  substance  which  is  manufactured  in  the  ovary  and  thrown  into 
the  circulating  blood.  This  action  is  designated  by  the  term  "internal 
secretion."  It  is  analogous  to  the  function  of  the  thyroid  gland,  which, 
though  it  possesses  no  duct,  manufactures  a  principle  which  finds  its  way 
into  the  circulation  and  exercises  a  marked  influence  over  the  general  -nutri- 
tion, as  evidenced  by  the  fact  that  when  the  thyroid  gland  is  destroyed  by 
disease  or  operation,  there  results  that  very  serious  condition  known  as 
mvxodema. 


POINTS   IN   PHYSIOLOGY  807 

That  the  powerful  trophic  influence  of  the  ovary  is  due  to  an  internal 
secretion  into  the  circulation,  and  not  to  reflexes  through  the  ovarian  nerves, 
is  indicated  hy  the  fact  that  if  the  ovaries  be  removed — i.  e.,  entirely  severed 
from  their  nervous  connections,  and  transplanted  to  another  part  of  the 
body — they  still  exercise  the  same  influence.  This  has  been  demonstrated 
over  and  over  again  by  various  authorities.  In  guinea  pigs  the  ovaries  were 
removed  from  the  pelvis  and  transplanted  under  the  skin,  with  the  result 
that  the  uterus  and  breasts  developed  normally.  As  the  ovaries  had  been 
entirely  severed  from  the  pelvic  nerves,  the  only  probable  way  for  them 
to  influence  the  uterus  and  breasts  was  through  the  circulation.  In  rabbits 
and  dogs  transplantation  of  the  ovaries  in  various  parts  of  the  body  have 
given  similar  results. 

In  the  human  patient  transplantation  of  an  ovary  from  one  patient  to  another 
has  been  successfully  carried  out  a  few  times  and  with  decidedly  beneficial 
results.  I  have  not  space  to  go  further  into  the  interesting  experiments  alonf? 
this  line.  Enough  has  been  said  to  show  that  the  ovary  has  two  important 
functions,  (1)  the  formation  of  the  ova  suitable  for  impregnation  and  (2) 
the  nutritional  effect  (probably  due  to  the  internal  secretion  into  the  cir- 
culation of  some  substance),  by  which  is  exercised  a  controlling  influence  on 
menstruation,  on  the  development  of  the  uterus  and  breasts,  and  on  certain 
nervous  disturbances. 

Based  on  the  latter  function  of  the  ovary  are  certain  therapeutic  measures 
which  have  come  into  prominence  in  the  last  few  years.    They  are  as  follows : 

1.  Leaving  Part  of  an  Ovary.  In  the  operative  treatment  of  ovarian  dis- 
eases, an  ovary  or  part  of  an  ovary  is  always  preserved  in  place  if  the 
pathological  condition  will  permit. 

2.  Administration  of  Ovarian  Tissue.  In  a  patient  in  whom  both  ovaries 
must  be  sacrificed,  the  patient  is  afterwards  given  desiccated  ovarian  tissue 
for  the  purpose  of  lessening  the  disturbances  of  the  artificial  menopause. 

3.  Transplantation  of  an  Ovary.  In  a  patient  presenting  serious  symptoms 
as  the  result  of  the  removal  of  both  ovaries  by  operation  or  their  destruction 
by  disease,  a  healthy  ovary  from  another  person  is  transplanted  to  the  pelvis 
of  the  chronic  invalid  to  supply  again  the  ovarian  trophic  substance. 

This  has  been  carried  out  successfully  in  several  instances.  In  one  patient 
the  transplantation  operation  was  made  two  years  after  both  ovaries  had 
been  removed.  The  patient  Avas  restored  to  health  and  there  was  also  partial 
restoration  of  the  menses.  Still  better  results  have  followed  the  immediate 
transplantation  of  a  healthy  ovary  during  the  primary  operation  in  which 
both  ovaries  were  so  diseased  that  they  had  to  be  removed.  In  at  least 
one  case  the  menstruation  continued  regularly  as  though  the  ovaries  had 
not  been  disturbed.  This  work  is  still  in  the  experimental  stage,  but  enough 
has  already  been  accomplished  to  show  that  a  healthy  ovary,  successfully 
transplanted,  can  continue  its  functions  and,  consequently,  that  many  women 
can  be  rescued  from  the  condition  of  chronic  invalidism  caused  by  destruction 
of  the  ovaries  or  by  imperfect  development  of  the  same. 


808 


TUMORS  OF  THE  OVARY  AND  PAROVARIUM 


Investigations  concerning  the  trophic  influence  of  the  ovary  indicates  that 
that  influence  comes  from  the  corpus  luteum.  In  fact  it  appears  that  the 
corpus  luteum  is  a  temporary  secreting  gland,  the  lutein  cells  being  the  active 
secreting  cells.  In  support  of  the  theory  that  it  is  the  secretion  of  the  lutein 
cells  that  controls  menstruation  and  exercises  the  general  trophic  influence 
due  to  the  ovary,  the  following  facts  have  been  cited : 

a.  In  the  transplantation  experiments  previously  mentioned,  if  the  trans- 
planted ovary  did  not  survive  in  such  condition  that  ovulation  took  place — i.  e., 
an  ovum  was  discharged  and  a  corpus  luteum  formed — ^no  trophic  influence 
was  apparent.    It  was  just  as  though  no  ovarian  tissue  were  present. 


\ 


Epooptioron,(Paroi^aTiuini  ,  . 

(Tcbules  «f  upper  part  «f  Welfrian  bortyj 


d  «f  Morjajm 


Gartners  duct ,  ^^  4,^,,„  ^^^^  j 


Fig.  682.     Adult  Genital  Organs,  showing  parovarium,  Gartner's  duct  and  various  other  structures, 
after  CuUen — Operative  Gynecology.) 


(Kelly 


b.  Destruction  of  the  corpus"  luteum  in  rabbits  in  the  early  part  of  preg- 
nancy prevented  .complete  development  of  the  pregnant  uterus  and  con- 
tained ovum.  The  effect  was  the  same,  whether  the  entire  ovary  was  removed 
or  simply  the  corpus  luteum  destroyed. 

c.  Destruction  of  the  corpus  luteum  in  the  non-pregnant  caused  the  next 
menstruation  to  be  missed,  indicating  that  the  secretion  of  the  lutein  cells 
of  the  corpus  luteum  of  each  period  prepared  the  uterus  for  the  menstrua- 
tion of  the  next  period. 


CLASSIFICATION  OF  TUMORS  OF  OVARY  809 

This  destniction  of  the  fresh  corpus  luteum  was  carried  out  in  a  series 
of  nine  women,  who  were  being  operated  on  for  malposition  or  similar 
troubles  that  did  not  interfere  with  the  observations.  In  eight  of  the  nine 
cases  the  next  menstruation  was  missed,  the  succeeding  menstruations,  how- 
ever, occurring  regularly. 

d.  In  that  class  of  cases  in  which  the  administration  of  desiccated  ovarian 
tissue  produces  beneficial  results,  the  administration  of  lutein  tissue  pro- 
duced similar  and  even  better  results,  indicating  that  the  active  principle 
of  ovarian  tissue  is  contained  in  the  lutein  cells. 

THE  PAROVARIUM. 

The  parovarium  is  the  remains  of  a  fetal  organ,  the  AVolffian  body,  which 
helps  to  form  the  generative  organs.  It  consists  of  a  triangular  group  of 
tubules  situated  in  that  part  of  the  broad  ligament  lying  between  the  ovarj' 
and  the  Fallopian  tube.  The  apex  of  the  triangle  lies  near  the  hilum  of  the 
ovary.  Beginning  near  the  hilum  of  the  ovary,  the  tubules  extend  upward, 
almost  parallel,  or  in  a  kind  of  fan-shaped  formation,  and  enter  a  transverse 
tube.  This  transverse  tube  is  called  the  "head  tube"  and  it  terminates  in  a 
small  cul-de-sac  near  the  fimbriated  extremity  of  the  Fallopian  tube  (Figs. 
681,  682).  Very  often  this  little  cul-de-sac  becomes  distended  with  fluid 
and  forms  a  miniature  cyst  on  the  surface  of  the  broad  ligament.  But  the 
little  cyst  thus  formed  is  apparently  distinct  from  another  miniature  cyst 
usually  found  in  the  same  vicinity  and  called  the  ''hydatid  of  Morgagni. " 
The  hydatid  of  Morgagni  is  the  dilated  end  of  another  fetal  structure — 
the  duct  of  Miiller,  which  forms  the  Fallopian  tube. 

Another  smaller  group  of  remnants  of  the  Wolffian  body  which  lies  nearer  the 
uterus  is  called  the  "paroophoron"   (Figs.  681,  682). 

The  tubules  of  the  parovarium  and  paroophoron  are  embedded  in  the  delicate 
connective  tissue  between  the  layers  of  the  broad  ligament  and  have  no  con- 
nection with  any  of  the  surrounding  organs. 

The  structure  has  no  function,  and  it  is  of  interest  chiefly  because  it  gives 
rise  to  certain  tumors  of  the  broad  ligament. 


CLASSIFICATION 

of  Tumors  of  the  Ovary. 

It  will  be  noticed  that  I  have  included  in  this  table,  under  simple  cysts, 
some  conditions  that  are  not  really  tumors  (new  growths),  but  only  inflam- 
matory and  nutritial  changes.  Clinically,  however,  they  resemble  so  closely 
certain  new  growths  that  I  think  best  to  consider  them  here.  Keeping  in 
mind  this  explanation,  and  also  the  fact  that  this  is  a  clinical  and  not  a  patho- 
logical classification,  there  should  be  no  confusion. 


O^Q  TUMORS  OF  THE  OVARY 

Ovarian  Tumors. 

Cystic  Tumors  (95%). 
Simple  Cysts. 

Follicular  Cysts. 

Cysts  of  Corpus  Luteum. 

Tubo-ovariau  Cysts. 
Proliferating  Cysts  (Cystadenomata). 

Pseudomucinous  Cysts  (Cystadenoma  Evertens). 

Serous  Cysts  (Cystadenoma  Invertens). 
Dermoid  Cysts. 

Solid  Tumors  (5%). 
Fibromata, 
Fibromyomata. 
Papillomata  (of  surface). 
Carcinomata. 
Sarcomata. 

CYSTIC  TUMORS  OF  THE  OVARY. 

These  comprise  simple  cysts,  proliferating  cysts  and  dermoid  cysts. 

DEFINITION  AND  PATHOLOGY. 

Simple  Cysts. 

Under  this  term  is  included  follicular  cyst,  corpus  luteum  cysts,  and  tubo- 
ovarian  cysts. 

Follicular  cysts  (Figs.  656,  683)  are  simply  unruptured  Graafian  follicles 
which  have  become  dilated.  The  increase  in  the  fluid  of  the  follicle  and  the 
consequent  formation  of  a  small  cyst  is  due  to  the  failure  of  the  follicle  to 
rupture.  This  failure  to  rupture  may  be  caused  by  the  deep  situation  of  the 
follicle  or  by  thickening  of  the  tunica  albuginea  (the  fibrous  coat  of  the 
ovary),  or  by  the  peritoneal  exudate  on  the  surface  of  the  ovary. 

These  follicular  cysts  are  small  and  rarely  produce  serious  symptoms.  They 
are  frequently  found  in  chronic  oophoritis,  and  an  ovary  may  contain  fifteen 
or  twenty  of  them  and  still  not  be  more  than  twice  its  normal  size.  Such  a 
condition  is  designated  by  the  term  "hydrops  folliculi"  and  also  by  the 
term  "cystic  ovary."'  Such  a  condition  is  not  an  indication  for  operation, 
unless  there  are  serious  complications  or  unusually  severe  symptoms.  Oc- 
casionally a  follicular  cyst  will  enlarge  to  the  size  of  tlie  fist  (Fig.  420),  but 
that  is  rare. 

It  was  formerly  supposed  that  the  large  proliferating  cysts  of  the  ovary 
were  derived  from  these  small  follicular  cysts,  but  that  theory  has  been 
abandoned. 


I 


SIMPLE  CYSTS 


811 


Corpus  luteum  cysts  (Fig.  684)  are,  as  their  name  indicates,  derived  from 
corpora  lutea,  Avliirli,  instead  of  undergoing  the  regular  process  of  absorption 
and  cicatrization,  undergo  a  cystic  change.  Microscopic  examination  of  the 
walls  of  such  a  cyst  will  show  the  lutein  cells,  characteristic  of  the  corpus 


Fig.  683.     Follicular  Cysts  of  the  Ovary.     (Kelly — Operative  Gynecology.) 


Fig.  684.     Corpus  Luteum  Cysts.     (Kelly — Operative  Gynecology.) 


luteum    (Fig.    685).     Corpus   luteum   cysts   are   usually  not  larger  than   an 
egg,  though  a  few  larger  ones  have  been  reported. 

Tubo-ovarian  cysts  are  those  cysts,  usually  small,  which  are  formed  by  the 


g^2  TUMORS  OF  THE  OVARY 

tube  and  the  ovary  combined  (Fig.  686).  A  simple  cyst  of  the  ovary  may 
rupture  into  an  adherent  tube,  or  a  dilated  tube  containing  fluid  (hydro- 
salpinx) may  become  adherent  to  an  ovary  and  rupture  into  it.  In  either 
case  the  wall  of  the  resulting  cavity  is  formed  by  both  the  tube  and  ovary ; 
hence  the  name  "tubo-ovarian."     These  cysts  are  usually  small. 


Fig.  685.     Layer  of  Lutein  Cells,  which  is  the  distingiiishiiig  element  in  the  wall  of  a  corpus  lutein  cys 
The  upper  part  of  the  drawing  indicates  the  appearance  of  the  corrugated  j'ellow  layer  in  the  cyst  wall,  while 
the  lower  portion  represents  a  high  magnification,  showing  the  indi\'idual  lutein  cells. 

None  of  the  conditions  described  under  simple  cysts  require  operation, 
unless  the  symptoms  are  very  troublesome  and  persistent.  If  the  condiiton 
is  discovered  in  the  course  of  an  abdominal  section  for  some  other  troul)le, 
the  pathological  -structure  should  ordinarily  be  removed,  with  the  sacrifice  of 
as  little  normal  tissue  as  possible. 

Proliferating  Cysts. 
These  are  the  ovarian  tumors  whicli  attain  such  a  large    size   (Fig.  687). 
This  is  the  form  of  growth  ordinarily  referred  to  when  an  "ovarian  cyst" 
or  "ovarian  tumor"  is  spoken. of. 


PROLIFERATING  CYSTS 


813 


The  term  ''proliferating''  is  given  to  these  growths  because  they  have  the 
faculty  of  generating  new  cysts  within  the  original  cyst  or  on  the  outside 
of  it.  They  increase  in  size  persistently  and  there  is  no  means  of  stopping 
their  growth,  except  removal. 


Fig.  686.  A  Tubo-ovarian  Cyst.  The  arrow,  passing  in  one  window  and  out  of  the  other,  indicates  the 
communication  between  the  ovarian  and  the  tubal  portion  of  the  cystic  mass. 

The  proliferating  cysts,  or  cystadenomata,  are  of  two  kinds — the  pseudo- 
mucinous and  the  serous. 

Pseudomucinous  Cystadenomata.  These  are  known  also  as  "paramuci- 
nous  cystadenomata"  and  as  "cystadenomata  evertens. "    In  these  cysts  the 


Fig.  687.     Patient  with  a  Large  Ovarian  Tumor. 


814 


TUMORS  OF  THE  OVARY 


contents  consist  of  a  jelly-like  material  Avliicli  is  secreted  by  the  epithelial 
cells  lining  the  cyst.  This  gelatinous  material  is  the  distinguishing  charac- 
teristic of  the  pseudomucinous  cyst  (Fig.  688).  On  chemical  examination 
it  shows  the  reaction  for  paramucin  or  pseudomucin  (not  precipitated  by 
acetic  acid,  but  precipitated  by  alcohol  as  delicate  threads,  which  are 
insoluble  in  water ;  mucin  is  precipitated  by  acetic  acid,  and  albumen  is  pre- 
cipitated by  heat).    The   color   of  this   gelatinous  material   depends   on  the 


Fig.  688.  A  Large  Psonilonuu-inous  Cystadenoma  of  the  Ovary.  In  this  case  the  contents  were  semi-solid 
like  jelly,  and  would  not  flow  through  the  largest  tube.  The  cyst  wall  was  so  friable  that  it  would  not  stand  the 
manipulations  necessary  to  scooping  out  the  cyst  contents,  so  it  was  necessary  to  remove  the  cyst  lilce  a  solid 
tumor  through  a  very  long  incision.  The  gelatinous  material  within  the  cyst  may  be  seen  protruding  through 
a  rent  in  the  wall  at  the  lower  part  and  also  at  the  upper  part. 

amount   oL"   lilood-eoloriug   Avliidi    has    diffused   through   it    from   hemorrhage 
into  the  cyst,  as  explained  laler. 

As  the  contents  are  formed  l)y  the  secretion  of  the  cells  lining  the  cyst, 
there  is  a  constant  increase  in  the  amount,  and  this  causes  constant  internal 
pressure,  which  keeps  the  wall  of  the  cyst  tense.  In  this  way  the  epitjielial 
layer  is  kept  spread  out  and  does  not  so  much  tend  to  pile  up  along  the  wall 
as  papillary  projections.     Rather  the  pressure  tends  to  depress  portions  of 


PATHOLOGY  OF  PROLIFERATING  CYSTS 


815 


the  wall,  and  as  the  epithelial  cells  multiply  they  are  pushed  further  out  in 
the  wall  in  the  form  of  gland-like  depressions — hence  the  name  "evertens. " 
The  depressions  may  become  occluded  at  the  neck  and  are  thus  cut  off-  from 
the  main  cavity,  forming  secondary  cysts  (Fig.  689).  These  secondary 
cysts  are  found  in  great  numbers  about  the  primary  cyst  and  occasionally 
one  or  more  of  the  secondary  cysts  may  become  as  large  as  the  primary  one. 
The  rule  that  pseudomucinous  cysts  are  evertent  is  not  absolute.  In 
nearly  all  such  cysts  there  are  a  few  insignificant  epithelial  ingrowths,  and 
in  rare  cases  these   growths  may  predominate,   giving   a   distinct   character 


Fig.  689.     A  Pseudomucinous  Cystadenoma  of  tlie  Ovary, 
the  wall  of  the  large  cyst.     (Kelly — Operative  Gynecology.) 


Notice  the  development  of  secondary  cysts  in 


to  the  growth  (pseudomucinous  cystadenoma  invertens.  Such  atypical 
pseudomucinous  cysts  are  nearly  always  small,  indicating  that  there  was 
not  much  internal  pressure. 

The  cells  lining  the  pseudomucinous  cyst  present,  on  microscopic  exami- 
nation, the  following  characteristics : 

They  contain  pseudomucin.  This  is  contained  in  the  inner  end  of 
the  cell  (the  end  next  to  the  cyst  cavity) — hence  this  end  of 
each  cell  remains  clear,  because  the  pseudomucin  does  not  take 
the  ordinary  stain  used  in  the  preparation  of  microscopic  speci- 
mens. (Fig.  690,  a). 
There  are  goblet  cells  scattered  here  and  there  amon^r  the  colum- 
nar cells. 
The  cells  are  not  ciliated. 


816 


TUMORS  OF  THE  OVARY 


The  pseudomucinous  cystadenomata  are  nearly  always  confined  to  the 
ovary  of  one  side,  being  bilateral  only  very  rarely.  Such  a  cyst  may  start 
as  a  unicentral  growth  (giving  one  large  cyst)  or  as  a  multicentral  growth 
(giving  two  or  more  primary  cyst  cavities). 

Pseudomucinous  cysts  very  rarely  rupture  spontaneously. 

They  rarely  form  peritoneal  metastases.  The  apparent  peritoneal  me- 
tastases that  result  from  rupture  of  such  a  cyst  or  from  contamination  dur- 
ing removal  are  due  simply  to  the  persistence  of  groups  of  cells  that  have 
lodged  on  the  peritoneum  and  secured  temporary  nourishment,  and  go  on 
for  a  time  producing  pseudomucin.  There  is  rarely  any  real  growth  or  mul- 
tiplication of  the  adherent  epithelial  cells.  They  usually  live  for  a  short 
time  only  and  then  disappear.  Occasionally,  however,  there  is  multiplication 
of  these  cells,  and  growth  all  through  the  abdominal  cavity,  giving  rise  to 
the  rare  condition  known  as   "pseudo-myxoma  peritonei."    The   peritoneal 


^-^J^^^&iuM 


-_.e-i.--r>   -."  '^  i: »  -nsr. 


A  B 

Fig.  690.     Indicating  the  difference  between  the  cells  lining  a  pseudomucinous  cyst    (A)    and   those  lining 
a  serous  cyst  (B),  as  explained  in  the  text. 


cavity  becomes  filled  with  the  pseudomucinous  material,  which  is  reformed 
again  and  again  after  removal.  Most  of  these  patients  finally  succumb  to 
meclianical  interference  by  the  spreading  pseudomucinous  growth  or  to  the 
secondary  development  of  malignant  disease. 

Pseudomucinous  cysts  rarely  undergo  malignant  change,  except  as  above 
stated. 

The  cause  of  the  pseudomucinous  cyst  is  not  known  certainly.  They 
probably  start  from  the  primordial  follicles.  This  is  indicated  by  the  fact 
that  in  the  small  secondary  cysts,  in  the  Avail  of  the  main  cyst,  perfect  ova 
have  been  found.  These  ova  were  formed  after  ])irth.  According  to  accepted 
theories,  the  only  cells  in  the  ovary  capable  of  forming  ova  after  birth  are 
those  of  the  primordial  follicles.  All  the  other  cells  have  been  differentiated 
past  this  stage. 

Serous  Cystadenomata.  These  are  known  also  as  "papillary  cysts"  and 
as  "cystadenomata  iuvertens. "     The   contents  of  the  serous   cyst  partakes 


PATHOLOGY  OF  PROLIFERATING  CYSTS 


817 


of  the  nature  of  serum  and  does  not  present  the  gelatinous  character  of  that 
of  the  pseudomucinous  variety.  On  chemical  examination  the  contents 
show  a  large  amount  of  albumen  and  no  pseudomucin.  The  contents  of  the 
serous  cysts,  like  that  of  the  other  variety,  may  vary  much  in  color  and 


Fig.  691.     A  Papillary  Cystadenoma  of  the  Ovary.     The  papillary  projections  within  the  cyst  grow  to  the 
opposite  wall  and  then  penetrate  it.     (Pfannenstiel — VeiVs  Hand-Buch.) 

consistency — this  variation  being  due  to  the  amount  of  hemorrhage  into 
the  cyst.  The  cells  apparently  have  no  secretion,  and  consequently  there  is 
no  marked  intra-cystic  pressure  as  there  is  in  the  pseudomucinous  cyst.  On 
account  of  this  absence  of  internal  pressure  the  cells,   as  they  proliferate, 


,>^ 


Fig  692.     A  Papillary  Cystadenoma,  sectioned  and  showing  the  papillary  projections  into  the  cyst  cavity. 
(Penrose — Diseases  of  Women.) 


818 


TUMORS  OF  THE  OVARY 


pile  up,  forming  papillary  projections  into  the  interior  of  the  cyst  (Figs.  691, 
692)— hence  the  name  '^nvertens."  These  papillary  masses  (consisting  of 
a  layer  of  epithelial  cells  and  some  stroma),  when  they  come  in  contact 
with  the  opposite  wall  of  the  cyst,  penetrate  the  wall  and  appear  outside  as 
papillary  growths  on  the  external  surface  of  the  cyst  (Fig.  693). 

Usually  a  few  gland-like  eversions  may  be  found  in  the  wall,  but  they  are 
insignificant.  Occasionally,  however,  a  serous  eystadenoma  will  present 
nearly  altogether  evertent  growths  (gland-like  projections  into  the  wall  of 
the  cyst) — serous  eystadenoma  evertens. 

The  cells  lining  the  serous  cyst  present  the  following  characteristics: 

They  contain  no  pseudomucin,   hence  they   stain  throughout    (Fig. 

690,  b). 
There  are  no  goblet  cells — all  plain  columnar  cells. 
They  have  cilia. 


Fig.  693.  Papillary  Cystadenoma  of  each  Ovary.  On  the  left  side  the  internal  papillary  projections  have 
grown  through  the  opposite  wall  and  appear  on  the  external  surface.  On  the  right  side  the  papillary  growths 
have  obliterated  all  resemblance  to  a  cyst,  and  appear  simply  as  a  cauUflower  growth  in  the  region  of  the  ovary. 
Notice  tlie  metastasis  on  the  peritoneal  surface  of  the  uterus.     (Penrose — Diseases  of  Women.) 


A  serous  cystadenoma  may  start  as  either  a  unicentral  or  a  pluracentral 
growth.  It  does  not  form  such  a  large  tumor  as  the  pseudomucinous  cyst, 
and  it  is  nearly  always  unilocular,  except  when  it  begins  as  a  pluracentral 
growth.  Serous  cysts  are  usually  bilateral  and  in  this  they  dilfer  markedly 
from  the  pseudomucinous  variety. 

A  striking  feature  of  tliese  serous  cysts  is  that  local  metastases  usually 
take  place.  When-  such  a  cyst  ruptures,  extensive  local  metastases  form  on 
adjacent  peritoi^eal  surfaces,  producing  papillomatous  growths.  These 
growths  show  no  malignant  structure,  but  they  may  kill  the  patient  by  ex- 
tensive local  groAvth,  tliough  they  do  not  penetrate  adjacent  organs  nor 
cause  distant  metastases.  They  may,  however,  and  in  fact  very  frequently  do, 
undergo  malignant  change,  in  which  case  they  become  ordinary  carcinomata. 

The  origin  of  the  serous  cysts  is  not  settled.    Some  authorities  hold  that 


THE   TWO   KINDS  OP  PROLIFERATING  CYSTS 


819 


tliey  arise  from  the  membrana  granulosa  of  tlio  Graafian  follicle.  It  is  held 
by  others  that  they  arise  from  parovarium  duet-remnants  in  the  ovary,  and 
there  are  some  facts  that  tend  to  support  this  theory.  In  structure  they 
resemble  closely  certain  parovarian  cysts,  and  remnants  of  parovarian  ducts 
are  found  in  the  ovary  near  the  hilum,  which  is  just  the  part  of  the  ovary 
from  which  these  cysts  apparently  take  their  origin.  ]\Ioreover,  they  differ 
from  the  common  form  of  ovarian  papilloma,  which  originates  from  tlic 
surface  layer  of  epithelium  (the  germinal  epithelium),  though  the  term 
''ovarian  papilloma"  is  sometimes  applied  to  the  papillomatous  growth  re- 
sulting from  the  early  rupture  of  a  serous  cyst  and  in  which  the  cyst  charac- 
ter has  largely  disappeared. 

The  characteristics  of  the  pseudomucinous  and  serous  cysts  may  be  pre- 
sented and  contrasted  concisely  as  follows : 


Proliferating  Cysts. 

(Cystadenomata.) 


Pseudomucinous  Cyst. 

(Cystadenoma  Evertens). 

1.  Contents  gelatinous  and  secreted 
by  the  cells  lining  the  cyst — may 
be  any  color. 

2.  Secondary  growths  consist  of  gland- 
like projections  outward  (evertent) 
from  the  cavity  into  the  wall,  form- 
ing small  cystic  cavities  in  the  wall. 


3.  Lining  cells  contain  pseudomucin, 
are  columnar,  with  some  goblet 
cells,  and  are  not  ciliated. 

4.  Nearly  always  unilateral. 

5.  Rarely  rupture  spontaneously. 


6.  Rarely  cause  peritoneal  metastases. 


7.  Rarely  undergoes  malignant  change.      7. 


8.  Very  common. 

9.  Cause    unknown.      Probably    start 
from  primordial  follicles. 


Serous  Cyst. 

(Cystadenoma  Invertens), 

1.  Contents  serum-like  and  not  secret- 
ed by  the  cells  lining  the  cyst — 
may  be  any  color. 

2.  Secondary  growths  consist  of  pap- 
illary projections  iuAvard  (invert- 
ent)  from  the  wall  into  the  cavity, 
forming  papillary  masses  which  ex- 
tend across  the  cavity  and  pene- 
trate the  opposite  wall. 

3.  Lining  cells  contain  no  pseudomu- 
cin, are  plain  columnar,  without 
goblet  cells,  and  are  ciliated. 

4.  Nearly  always  bilateral. 

5.  Usually  rupture  at  an  early  stage, 
because  of  perforation  of  the  wall 
by  the  papillary  ingrowths. 

6.  Usually  cause  peritoneal  metasta- 
ses, consisting  of  widespread  papil- 
lary growths. 

Frequently    undergoes     malignant 
change. 
Rare. 

Cause  unknown.  Prol)al)ly  start 
from  parovarian  tube-remnants  in 
the  ovary. 


820  TUMORS  OF  THE  OVARY 

Taking  up  the  clinical  manifestations  of  the  proliferating  cysts  (both 
pseudomucinous  and  serous),  it  is  found  that  they  may  occur  at  any  age,  but 
are  most  frequent  during  the  period  of  greatest  ovarian  activity — i.  e.,  be- 
tween the  twentieth  and  fiftieth  years.  Either  ovary  may  be  affected.  They 
are  bilateral  in  only  about  3  per  cent,  of  the  cases,  while  malignant  tumors  of 
the  ovary  are  bilateral  in  about  75  per  cent,  of  the  cases.  As  I  mentioned  be- 
fore, the  serous  or  papillary  proliferating  cysts  are  usually  bilateral,  but  they 
constitute  only  a  small  proportion  of  proliferating  cysts — most  of  such  cysts 
being  of  the  pseudomucinous  variety. 

In  shape,  a  proliferating  cyst  may  be  spherical  and  regular  in  outline,  indi- 
cating a  single  large  cyst,  or  it  may  be  irregular,  presenting  nodules  indicat- 
ing a  multilocular  cyst.  In  size  these  cysts  vary  from  a  small  tumor  the  size 
of  an  egg  to  a  large  tumor  filling  the  whole  abdomen. 

As  to  appearance  when  exposed  by  abdominal  incisions,  the  wall  of  the  cyst 
presents  a  white,  glistening  appearance.  The  thinner  portions  are  straw- 
colored  or  green  or  black,  according  to  their  fluid  contents.  The  surface  of  the 
cyst  may  be  perfectly  smooth  or  may  be  covered  by  a  papillary  growth,  or 
may  be  bound  to  adjacent  structures  by  adhesions.  The  tumor  usually  has  a 
distinct  pedicle. 

The  cysts  are  divided  into  three  classes  according  to  their  internal  struc- 
ture— unilocular,  multilocular  and  areolar.  Unilocular  cysts  may  be  very 
large,  but  they  are  found  to  consist  of  only  one  large  cyst.  However,  the  in- 
terior frequently  shows  remains  of  trabeculae,  indicating  that  they  were  at 
one  time  multilocular  cysts.  Multilocular  cysts  contain  two  or  more  cysts  of 
medium  size,  besides  a  large  number  of  smaller  cavities  (Fig.  689).  Areolar 
cysts  are  made  up  of  a  large  number  of  small  cavities  of  various  sizes  and 
shapes. 

The  cyst  wall  consists  of  three  layers — an  outer  and  inner  firm  fibrous 
layer,  with  a  middle  layer  of  looser  tissue  between  them.  In  the  middle  layer 
of  loose  connective  tissue  the  vascular  supply  is  distributed.  Those  vessels 
which  come  near  the  outer  surface  may  often  be  plainly  seen,  and  they  are 
frequently  very  large.  The  external  surface  of  the  cyst-wall  is  covered  with 
columnar  epithelium,  derived  from  the  germinal  epithelium  covering  the  sur- 
face of  the  ovary  and  differing  from  the  endothelium  of  the  peritoneum.  The 
internal  surface  is  lined  with  low  columnar  cells.  The  lining  membrane  is 
often  covered  with  vegetations  and  irregular  growths,  both  cystic  and  solid. 

The  contents  of  cysts  present  marked  contrast  in  consistency  and  in  color. 
The  contents  may  be  thin  like  water  (serous  cysts),  or  thick  and  viscid  and  of 
gelatinous  consistency  (pseudomucinous  cyst).  The  contents  may  be  almost 
colorless  or  straw-colored  or  a  dirty  yellow,  or  green  or  black.  The  color  de- 
pends on  hemorrhage  into  the  cyst.  The  coloring  matter  of  the  blood  becomes 
the  coloring  matter  of  the  cyst  contents. 

As  these  cysts  enlarge  they  bear  various  relations  to  adjacent  structures. 
If  they  rise  out  of  the  pelvis  and  enlarge  in  the  abdomen,  they  may  attain  a 
very  large  size  before  producing  serious  symptoms.  They  there  have  plenty  of 


DERMOID  CYSTS 


821 


room  and  expand  freely,  pushing  aside  the  surrounding  organs.  If  they  be- 
come caught  under  the  pelvic  brim  and  develop  in  tlie  pelvis,  they  soon  begin 
to  cause  pain  and  other  disturbances  from  pressure  and  distortion  of  the 
organs. 

The  proliferating  papillary  cysts,  or  serous  cysts,  before  described,  usually 
rupture  rather  early  and  fill  the  pelvis  with  papillary  growths.  In  such  a  case 
the  first  impression,  when  the  abdomen  is  opened,  is  that  the  pelvis  is  filled 
with  a  cancerous  mass,  which  cannot  be  removed  and  which  will  soon  cause 
death.  Accordingly,  in  not  a  few  cases,  the  operator,  after  scraping  out  some 
of  the  papillary  bleeding  growth,  has  closed  the  abdomen  and  told  the  pa- 
tient or  her  friends  that  there  was  an  inoperable  cancer  and  that  she  could 
not  long  survive.  Some  such  patients  get  entirely  well  after  the  operation. 
In  other  cases  malignant  change  has  already  begun  or  begins  later  and  the 
patient  dies  of  carcinoma.  In  still  other  cases  the  growth  itself  becomes  so 
extensive  as  to  interfere  with  the  functions  of  adjacent  organs  and  thus 
causes  death. 

Dermoid  Cysts  of  the  Ovary. 

Dermoid  cysts  are  those  in  which  are  found  skin  or  mucous  membrane, 
associated  with  structures  generally  connected  with  the  epidermal  tissues. 
The  structures  most  frequently  found  are  hair,  teeth,  bone,  muscle-fibers,  skin 
and  small  balls  of  sebaceous  material  resembling  fat  (Figs.  694,  695,  696,  697). 


Fig.  694      Portion  of  the  Wall  of  a  Dermoid  Cyst  of  the  Ovary,     a,  Wall  of  cyst,     b,    Mass  of  cutaneous 
tissue     c,  Hair,     d,  Teeth.     (Thomas  and  Munde,  after  Ziegler — Diseases  of  Women.) 


822 


TUMORS  OF  THE  OVARY 


Fig.  695.  A  small  Dermoid  Cyst,  showing  teeth,  hair,  sebaceous  material  and  firm  fat-tissue.  The  teeth, 
shown  in  the  right  side,  are  unusually  well  developed  and  constitute  a  point  of  special  interest  in  this  specimen. 
(Specimen  of  Dr.  F.  J.  Tau.ssig.) 


Fig.  69G.  Hair,  five  and  a  half  feet  long, 
from  a  Dermoid  Cyst.  (Thomas  and  Munde 
— Diseases  of  Women.) 


Fig.  697.  Bails  of  Sebaceous 
Material  from  a  Dermoid  Cyst. 
(Thomas  and  Munde — Diseases  of 
Women.) 


SYMPTOMS  OF   OVARIAN  CYSTS  g23 

Dermoid  tumors  may  appear  at  any  age.  They  have  been  found  in  chil- 
dren at  birth  and  in  women  of  ninety  years. 

Dermoid  tumors  of  the  ovary  are  comparatively  small,  rarely  getting  larger 
than  a  child's  head.  But  they  are  more  dangerous  than  the  ordinary  large 
cysts,  for  the  dermoid  cysts  usually  present  more  and  firmer  adhesions,  and 
their  contents  are  more  irritating,  so  much  so  that  the  escape  of  any  of  the 
contents  into  the  peritoneal  cavity  is  likely  to  cause  a  fatal  peritonitis.  They 
are  much  more  liable  to  suppuration  and  consequent  abscess  formation  than 
the  ordinary  cysts. 

SYMPTOMS  AND  DIAGNOSIS 

of  Ovarian  Cysts. 

As  the  simple  cysts  seldom  give  rise  to  serious  trouble  and  the  dermoid 
cysts  are  rare,  the  symptoms  to  be  mentioned  belong  to  the  proliferating 
cysts  and  principally  to  the  pseudomucinous  variety,  as  the  vast  majority  of 
cystic  ovarian  tumors  belong  to  this  class. 

An  ovarian  cyst  usually  develops  slovs^ly  and  may  attain  considerable  size 
before  it  is  discovered.    Often  it  is  noticed  then  only  by  accident. 

The  earliest  symptoms  are  a  feeling  of  v^eight  and  pressure  in  the  pelvis, 
bladder  irritability,  slight  menstrual  disturbance,  constipation  and  perhaps 
some  pain  with  bowel  movement.  The  symptoms  are  not  distinctive,  but  sim- 
ply indicate  some  disturbing  factor  in  the  pelvis.  As  the  tumor  increases  in 
size,  distinct  pressure-symptoms  appear  and  the  general  nutrition  becomes 
affected.  There  is  enlargement  of  the  abdomen,  swelling  of  the  feet  from 
pressure  on  veins,  pain  from  pressure  on  nerves  and  dyspnoea  from  pressure 
on  the  diaphragm.  There  appear,  also,  stomach  disturbances,  emaciation  and 
progressive  weakness.  In  some  cases  there  are  attacks  of  local  peritonitis, 
with  severe  abdominal  pain  and  some  fever,  but  these  inflammatory  symp- 
toms are  due  to  complications  and  do  not  belong  to  the  natural  history  of  the 
tumor. 

Ovarian  cysts  grow  slowly,  usually  taking  several  years  to  reach  a  large 
size.  But  they  seldom  stop  growing.  They  persistently  enlarge  until  the  pa- 
tient finally  dies  from  exhaustion  brought  about  by  pressure-effects  on  vital 
organs. 

The  diagnosis  in  typical  cases  is  easy,  but  in  complicated  cases  it  may  be 
very  difficult,  and  in  exceptional  cases  a  positive  exact  diagnosis  is  impossi- 
ble before  operation.  Tapping  the  cyst  through  the  abdominal  wall  as  an 
explorative  measure  should  not  be  employed.  An  adherent  coil  of  intestine 
may  be  punctured,  or  cyst  contents  may  leak  into  the  peritoneal  cavity  and 
cause  fatal  peritonitis.  In  a  doubtful  case  an  exploratory  abdominal  section  is 
safer  and  far  more  satisfactory  in  diagnostic  results. 

In  taking  up  the  differential  diagnosis  of  ovarian  cysts,  it  is  at  once  appar- 
ent that  the  symptoms  and  diagnostic  points  are  different  in  the  different- 
sized  tumors. 


324  TUMORS  OF  THE  OVARY 

Small  Ovarian  Cyst. 

Considering  tlie  small  ovarian  cyst  according  to  the  "Points  in  the  Differ- 
ential Diagnosis  of  Various  Masses  in  the  Pehis  and  Lower  Abdomen" 
(Diagnostic  Table,  page  287),  it  is  found  that  an  ovarian  cyst  of  this  size  pre- 
sents the  following  characteristics  (the  numbers  refer  to  the  "Points"  in  the 
Diagnostic  Table). 

1.  Is  situated  in  the  lateral  part  of  the  pelvis,  though  in  exceptional  cases 
it  may  drop  down  directly  behind  the  uterus  or  in  front  of  it. 

2.  The  small  ovarian  cyst  is  the  size  now  under  consideration — about  as 
large  as  the  fist  or  a  little  larger. 

3.  Is  approximately  spherical,  though  may  be  made  uneven  by  secondary 
cysts. 

4.  Contains  fluid  (fluctuates). 

5.  Is  not  tender,  unless  complicated  hy  inflammation  or  by  torsion  of 
pedicle. 

6.  Is  freely  movable,  unless  complicated  by  adhesions  or  caught  under  the 
sacral  promontory. 

7.  Is  attached  in  the  lateral  part  of  the  pelvis. 

8.  Apparently  arises  from  the  tubo-ovarian  region. 

9.  Lies  beside  the  uterus,  but  is  not  attached  to  it  and  does  not  ordinarily 
modify  it  in  any  way,  except  to  cause  some  displacement  towards  the  opposite 
side. 

18.  Occupies  the  tubo-ovarian  region. 

36.  Symptoms  slight,  unless  complicated.  Xo  history  of  fever  or  of  attacks 
of  pehuc  inflammation. 

50.  Progressive  increase  in  size,  without  inflammatory  symptoms. 

57.  Fallopian  tube  lies  close  to  the  mass,  but  can  in  some  cases  be  distin- 
guished from  it.  The  ovary  is  not  found  because  incorporated  in  the  mass. 
The  uterus  is  of  normal  size,  though  it  may  be  somewhat  displaced.  The  mass 
is  freely  movable,  unless  complicated,  and  can  be  separated  from  the  uterus 
and  from  the  pelvic  wall  and  from  the  Fallopian  tube  and  from  most  of  the 
broad  ligament,  but  not  from  the  ovary. 

The  following  conditions  may  be  confounded  with  a  small  ovarian  cyst  and 
must  therefore  be  taken  into  consideration  in  the  differential  diagnosis; 

a.  Inflammatory  ]\Iass   (salpingitis  with  exudate,  pyosalpinx,  hydro- 
salpinx). 

b.  Tubal  Pregnancy. 

c.  Fibroid  Tumor  of  the  Uterus. 

d.  Retroverted  Pregnant  Uterus. 

e.  Broad  Ligament  Cyst. 

a.  Inflammatory  Mass.  There  are  three  kinds  of  masses  resulting  from  in- 
flammation or  allied  conditions  that  must  be  taken  into  consideration. 

Salpingitis  with  exudate  presents  a  mass  which  is  (1)  situated  in  the  tubo- 


DIFFERENTIAL  DIAGNOSIS  825 

ovarian  region,  (2)  irregular  in  shape,  (3)  firm,  (4)  very  tender,  (5)  fixed 
by  adhesion,  (6)  attached  to  both  the  pelvic  wall  and  the  uterus,  (7)  appar- 
ently originates  in  adnexal  region,  (8)  attached  to  upper  lateral  part  of 
uterus,  but  a  sulcus  can  be  made  out  between  the  uterus  and  the  mass, 
(15)  uterus  fixed,  but  not  otherwise  modified  except  perhaps  somewhat  dis- 
placed to  the  opposite  side,  and  (16)  there  is  discharge  from  the  uterus  due 
to  the  preceding  endometritis.  The  tube  and  ovary  are  (18)  included  in  the 
mass,  (19)  the  mass  is  adherent  to  the  pelvic  wall,  (23)  there  may  be  a  mass 
about  the  opposite  tube,  (32)  there  is  fever  if  the  trouble  is  acute,  there  is  a 
history  of  (36)  sudden  onset,  with  pain  in  the  lower  abdomen  and  fever,  and 
confinement  to  bed  following  labor  or  miscarriage  or  instrumentation,  or 
gonorrhoea  or  chronic  endometritis,  (37)  remissions  and  exacerbations  with 
pelvic  pain  and  disability,  (38)  menstrual  disturbance  (usually  painful  men- 
struation), (40)  leucorrhoea,  (41)  backache  practically  all  the  time  and  ache- 
ing  in  pelvis,  with  sharp  pain  in  pelvis  during  the  exacerbations,  (42)  fever 
more  or  less  during  the  exacerbations,  (43)  some  disability  all  the  time  and 
usually  confined  to  bed  for  a  few  days  or  longer  during  the  exacerbations. 
Any  increase  in  size  (50)  is  accompanied  by  inflammatory  symptoms.  If  the 
patient  is  examined  under  anesthesia,  it  is  found  that  (51)  the  mass  occupies 
the  region  of  the  tube  and,  usually,  includes  the  ovary  also,  (53)  is  firm 
throughout,  (54)  is  fixed  by  adhesions,  (55)  is  attached  to  surrounding  or- 
gans, (56)  originates  from  the  tube  or  ovary,  (57)  the  mass  can  be  differen- 
tiated from  the  uterus,  but  not  from  the  tube  and  usually  not  from  the  ovary, 
and  (58)  the  uterus  is  normal  except  for  the  leucorrhoeal  discharge  and  the 
fixation,  and  perhaps  some  displacement  towards  the  opposite  side. 

Pyosalpinx  presents  practically  the  same  symptoms  and  signs,  except  that 
the  one  or  more  points  of  fluctuation  are  present  and  the  tenderness  is  more 
marked,  and  the  inflammatory  symptoms  and  exacerbations  are  more  severe. 

In  hydrosalpinx  the  inflammatory  symptoms  have  practically  disappeared, 
leaving  the  distended  fluctuating  tube  with  some  adhesions.  It  differs  from 
the  ovarian  cyst  in  that  (3)  the  mass  in  typical  cases  is  elongated  and  ''sau- 
sage-shaped," (6)  is  less  movable  than  the  ovarian  tumor,  (7)  is  attached  to 
the  pelvic  wall  and  to  the  uterus,  though  in  some  cases  the  attachment  is  not 
very  close,  (8)  appears  to  arise  from  all  along  the  upper  margin  of  the  broad 
ligament,  (18)  the  tube  is  included  in  the  mass,  while  the  ovary  can  in  some 
cases  be  differentiated,  (36)  there  is  a  history  of  previous  pelvic  inflamma- 
tion, (38)  menstrual  disturbance  and  other  evidence  of  previous  inflamma- 
tion in  the  uterus,  and  (57)  if  patient  is  examined  under  anesthesia  it  may 
usually  be  determined  definitely  that  the  tube  is  involved  in  the  mass  and 
that  the  ovary  is  separate. 

b.  Tubal  Pregnancy  presents  the  pain,  disability,  tenderness  and  fixation 
of  an  inflammatory  mass,  with  little  or  no  fever,  but  with  the  addition  of  the 
special  evidences  of  extra-uterine  pregnancy  given  in  the  previous  chapter 
(page  773). 

c.  Fibroid  Tumor  of  uterus  presents  a  mass  which  differs  from  an  ovarian 


826  TUMORS  OF  THE  OVARY 

cyst  in  that  it  is  (1)  situated  near  the  center  of  the  pelvis,  (3)  irregular  in 
shape,  (4)  firm  throughout,  or  if  it  is  a  cystic  fibroid  the  larger  part  of  the 
mass  is  firm,  (6)  not  movable  separately  from  the  uterus,  but  the  mass  and 
the  uterus  are  movable  in  the  pelvis,  (7)  attached  to  the  uterus,  (8)  appar- 
ently arises  from  the  uterus,  and  (9)  is  so  intimately  associated  with  the 
uterus  that  it  seems  to  be  part  of  the  organ.  The  uterus  is  usually  (10)  dis- 
placed somewhat  by  the  mass,  (11)  increased  in  size,  (12)  irregular  in  shape 
and  (16)  presents  some  discharge  from  the  accompanying  endometrical  dis- 
turbance. There  are  (23)  likely  to  be  other  masses  projecting  from  the 
uterus  and  there  is  a  history  of  (38)  menstrual  disturbance  (usually  ex- 
cessive menstruation),  (40)  leucorrhoea,  (41)  pressure  and  aching  in  the 
pelvis  and  (57)  if  the  patient  be  examined  under  anesthesia  it  is  found  that 
the  mass  is  intimately  associated  with  the  uterus  and  that  the  tubes  and 
ovaries  are  separate,  unless  the  mass  is  so  large  as  to  obscure  these  structures. 

d.  Retroverted  Pregnant  Uterus.  This  would  cause  confusion  in  diagnosis 
only  when  incarcerated  in  the  pelvis  so  that  it  could  not  be  raised  sufficiently 
to  be  brought  forward  nor  satisfactorily  outlined.  It  would  then  differ  from 
an  ovarian  cyst  in  that  the  mass  is  (1)  situated  in  the  median  line,  (4)  partly 
solid,  (5)  tender,  (6)  not  movable,  (7)  filling  posterior  part  of  pelvis,  (8) 
seems  to  be  a  continuation  of  the  cervix  uteri  and  (9)  apparently  the  ex- 
panded uterus  containing  fluid.  There  is  softening  (13)  of  the  cervix  and  cor- 
pus uteri  and  (17)  venous  discoloration  of  the  cervix  and  vagina.  There  is 
a  history  of  (38)  amenorrhoea,  (46)  morning  sickness  and  (47)  pains  and 
tenderness  in  the  breasts.  If  the  patient  is  examined  under  anesthesia  (57), 
the  mass  is  identified  with  the  uterus  (enlarged,  softened,  retroverted  and 
containing  fluid),  and  the  tubes  and  ovaries  are  distinguished  as  separate  un- 
less the  mass  is  so  large  that  it  obscures  them. 

e.  Broad  Ligament  Cyst.  This  differs  from  the  ovarian  cyst  in  that  it  is 
(1)  situated  deeper  in  the  pelvis,  (6)  not  so  movable,  (7)  attached  to  pelvic 
wall  and  uterus,  (8)  originates  in  the  lateral  pelvic  region,  (9)  extends  down 
the  side  of  the  uterus  toward  the  cervix,  (10)  displaces  the  uterus  markedly 
toward  the  opposite  side  and  (15)  fixes  the  uterus  to  some  extent.  If  the  pa- 
tient be  examined  under  anesthesia,  it  is  found  (57)  that  the  mass  is  located 
in  the  broad  ligament  below  the  tube,  and  the  tube  and  ovary  can  be  dis- 
tinguished as  separate  unless  obscured  by  the  mass. 

Large  Ovarian  Cyst. 

A  growth  large  enough  to"  cause  the  abdomen  to  be  prominent  must  be  dif- 
ferentiated from  the  following  conditions : 

a.  Tympanites  and  ''Phantom  Tumor." 

b.  Obesity. 

c.  General  Ascites. 

d.  Pregnancy  (normal,  with  hydramnios,  extra-uterine). 

e.  Cystic  Fibroid  of  Uterus, 


DIFFERENTIAL  DIAGNOSIS  827 

f.  Distended  Bladder. 

g.  Tiinior  of  some  al)(l()iiiiii;il  oi-^'aii. 
li.  Tul)ercii]ai'  Peritonitis. 

a.  Tympanites  presents  resonance  over  all  the  abdomen.  The  vagino-abdomi- 
nal  examination  shows  that  there  is  no  abdominal  mass  in  the  pelvis  or  lower 
abdomen  (P^ig.  132).  "Phantom  tumor"  is  a  term  applied  to  certain  condi- 
tions produced  by  irregular  contraction  of  the  abdominal  muscles  (forcing 
tympanitic  intestines  into  some  locality  in  such  a  way  as  to  give  the  appear- 
ance of  a  tumor),  accompanied  with  marked  hyperesthesia.  It  occurs  usually 
in  hysterical  subjects  and  the  apparent  tenderness  may  be  so  marked  as  to 
prevent  satisfactory  palpation,  either  abdominal  or  bimanual.  Usually  it  can 
be  made  out  that  there  is  distinct  resonance  over  the  swelling  and  that  there 
is  no  abnormal  mass  in  the  pelvis.  "When  in  doubt,  examine  the  patient  under 
anesthesia,  when  the  muscular  tension  and  the  consequent  "tumor"  will  disap- 
pear. 

b.  Obesity  may  produce  marked  prominence  of  the  abdomen  and  has  been 
mistaken  for  ovarian  cyst  (Fig.  122).  Resonance  may  be  obtained  in  deep, 
percussion  over  all  the  abdomen,  showing  that  there  is  no  mass  betw^een  the 
intestines  and  the  abdominal  wall  Also,  in  picking  up  the  wall  to  test  its 
thickness  (Figs.  119,  120)  it  is  found  that  most  of  the  prominence  is  due  to 
the  thickness  of  the  waU.  On  vagino-abdominal  examination  no  abnormal 
mass  is  felt  in  the  pelvis  or  lower  abdomen. 

c.  General  Ascites  presents  ordinarily,  when  the  patient  is  lying  on  her 
back,  resonance  at  the  top  of  the  abdomen  and  dullness  in  the  flanks  (Figs. 
185,  186).  "When  the  patient  changes  posture  the  outline  of  dullness  changes, 
as  the  free  fluid  goes  to  the  lowest  part  of  the  peritoneal  cavity  (Fig.  188). 
There  is  a  percussion  wave  in  ascites  (Figs.  35,  36).  Vagino-abdominal  ex- 
amination shows  that  there  is  no  mass  in  the  pelvis  or  lower  abdomen.  The 
presence  of  disease  of  the  heart  or  liver  or  kidneys  sufficient  to  account  for 
the  ascites  is  a  point  in  favor  of  the  same. 

d.  Preg'nancy.  Normal  pregnancy  presents  missed  menses,  morning  sick- 
ness, enlarged  breasts,  vaginal  and  cervical  discoloration  and  softening  of  the 
cervix.  The  examiner  can  usually  distinguish  the  fetal  parts  and  may  be  able 
to  feel  fetal  movements  or  hear  the  fetal  heart  sounds.  In  pregnancy  with 
hydramnios  the  symptoms  and  signs  are  about  the  same  as  in  normal  preg- 
nancy, except  that  there  is  more  fluid,  and  consecjuently  it  is  the  more  difficult 
to  feel  the  fetus  or  to  get  the  fetal  heart  sounds.  In  extra-uterine  pregnancy 
there  are  the  usual  symptoms  of  pregnancy,  with  the  addition  of  certain 
anomalous  symptoms,  indicating  that  the  pregnancy  is  in  the  peritoneal 
cavity  instead  of  within  the  uterus.  Also,  in  the  early  history  of  the  trouble 
there  are  indications  of  pelvic  inflammation,  with  the  added  special  character- 
istics of  tubal  pregnancy  enumerated  in  the  preceding  chapter  (page  773). 

e.  Cystic  Fibroid.  This  presents  an  irregular  mass  situated  in  the  central 
part  of  the  pelvis,  and  apparently  it  arises  from  or  is  a  part  of  the  uterus, 
from  which  it  can  not  be  separated.   A  large  part  of  the  mass  is  firm.   It  dis- 


g28  TUMORS  OF  THE  OVARY 

torts  the  uterus  and  increases  the  length  of  the  ca^dty.    There  is  usually  a 
history  of  excessive  menstruation  and  of  leucorrhoeal  discharge. 

f.  Distended  Bladder.  It  has  happened  that  a  distended  bladder  went  un- 
recognized until  rupture  of  the  bladder  and  death  of  the  patient.  In  a  case 
of  distended  bladder  the  history  shows  first  difficulty  in  passing  urine  and 
later  constant  dribbling  of  urine  due  to  the  overdistention.  There  may  be 
symptoms  of  uremia.  When  the  patient  is  catheterized  the  supposed  tumor  dis- 
appears, but  it  may  require  a  very  long  catheter  to  reach  the  urine  because  of 
the  distortion  and  lengthening  of  the  urethra. 

g.  Tumor  of  Some  Abdominal  Organ.  This  presents  the  fixed  or  least 
movable  portion  at  some  organ  in  the  abdomen,  the  rounded  free  border  ex- 
tending toward  the  pelvis  or  into  the  pelvis.  The  mass  may  be  displaced  up- 
ward into  the  abdominal  cavity  and  then  the  pelvis  is  clear.  There  are  symp- 
toms associated  with  the  organ  involved,  and  no  particular  symptoms  of  dis- 
turbance of  the  pelvic  organs. 

h.  Tubercular  Peritonitis.  There  is  fluid  in  the  abdominal  cavity,  either 
free  or  encysted,  associated  with  evidences  of  tubercular  inflammation  in  the 
pelvis  (page  763)  or  in  the  abdominal  cavity  or  in  both.  There  are  frequently 
evident  signs  of  tuberculosis  elsewhere,  usually  in  the  lungs  or  in  the  intes- 
tines. The  tuberculin  reactions  may  aid  materially  in  determining  whether 
the  intra-abdominal  trouble  is  tubercular. 

COMPLICATIONS. 

Having  determined  that  an  ovarian  cyst  is  present,  we  must  then  consider 
certain  complications  that  may  be  present  or  that  may  appear  later.  These 
complications  are  as  follows : 

1.  Local  peritonitis,  forming  adhesions. 

2.  Hemorrhage  into  the  cyst. 

3.  Rotation  of  the  cyst,  producing  torsion  of  the  pedicle. 

4.  Inflammation  and  suppttration  of  the  cyst. 

5.  Rupture  of  the  cyst. 

6.  Ascites  accompanying  the  tumor. 

7.  Intestinal  obstrtietion. 

1.  Local  peritonitis  is  accompanied  with  some  pain  and  tenderness  over 
a  part  of  the  tumor.  There  may  be  some  fever,  but  usually  this  symptom  is 
not  marked;  the  process  consists  simply  of  irritation  at  some  portion  of  the 
outer  surface  of  the  cyst  and  .tlie  formation  tliere  of  plastic  exudate,  binding 
the  cyst  to  some  adjacent  organ  or  to  the  abdominal  wall.  In  a  few  days  tbe 
pains  disappear, 'l)ut  the  exudate  remains,  becomes  organized  and  forms  an 
adhesion,  whidi  may  iulciTcre  more  or  less  with  the  subsequent  operation. 

2.  Hemorrhage  into  the  cyst  is  what  gives  tlie  various  colors  to  the  cyst 
contents.  This  liemorrliage  tisnally  takes  place  slowly  in  small  (inantities  and 
without  clinical  symptoms.  Occasionally,  however,  a  copious  hemorrhage 
takes  place,  usually  from  some  interefence  with  the  venous  return,  such  as 


COMPLICATIONS 


829 


twisting  of  the  pedicle  or  pressure  of  an  enlarged  uterus,  or  it  may  follow 
tapping  of  the  cyst.  The  hemorrhage  may  be  so  severe  as  to  cause  collapse 
of  the  patient. 

3.  Rotation  of  the  cyst  may  take  place  where  the  pedicle  is  long   (Pigs. 
427,  698).    The  amount  of  rotation  varies  from  a  half  turn  to  several  corn- 


Fig.  698.  Rotation  of  an  Ovarian  Cyst.  The  turning  of  the  tumor  twists  the  pedicle,  bIocl<ing  the  circula- 
tion and  causing  thrombosis  in  the  pedicle  and  throughout  the  tumor.  The  extravasation  of  blood  causes  the 
affected  tissues  to  become  black. 

plete  turns.  Torsion  of  the  pedicle  is  supposed  to  be  favored  by  an  injury, 
such  as  a  fall  or  blow,  and  by  active  exercise,  and  also  by  the  alternate  filling 
and  emptying  of  the  bladder  and  the  bowel,  and  during  pregnancy  by  the  en- 
largement of  the  uterus. 


830  TUMORS  OF  THE  OVARY 

The  effect  of  torsion  of  the  pedicle  on  the  circulation  of  the  tnmor  depends, 
of  course,  on  the  amount  of  rotation.  The  veins  are  the  iirst  to  suffer.  The 
flow  of  blood  in  them  is  impeded,  causing  the  tumor  to  become  engorged,  and 
there  is  hemorrhage  into  the  interior  of  the  cyst,  either  in  the  form  of  extrav- 
asation or  the  rupture  of  a  vein  with  severe  hemorrhage.  If  the  twisting 
increases,  there  is  thrombosis  of  the  vessels  and  extravasation  of  bloody  fluid 
into  the  peritoneal  cavity,  and  later  necrosis  of  the  tumor,  followed  by  fatal 
peritonitis.  The  hemorrhage  into  the  tumor  causes  it  to  appear  black  (Fig. 
687).  The  symptoms  of  torsion  of  the  pedicle  are  very  marked.  When  a  pa- 
tient with  an  ovarian  tumor  complains  of  sudden  pain  in  the  abdomen  and  has 
vomiting,  and  there  is  a  sudden  increase  in  the  size  of  the  tumor,  it  is  prob- 
able that  torsion  of  the  pedicle  has  taken  i3lace.  In  some  cases  there  are  re- 
peated attacks  of  slight  torsion. 

4.  Inflammation  and  Suppuration  of  the  Cyst.  This  is,  of  course,  due  to 
infection.  The  infection  may  come  from  the  intestinal  canal  or  from  the  blad- 
der or  from  a  Falliopian  tube  or  from  tapping  the  cyst.  The  most  common 
source  of  infection  is  the  Fallopian  tube.  The  patient  contracts  salpingitis, 
adhesions  form  between  the  inflamed  tube  and  the  cyst  wall,  and  infection 
spreads  along  these  adhesions  and  invades  the  cyst.  Adhesions  with  some 
portions  of  the  intestinal  tract,  especially  with  the  appendix,  may  likewise 
lead  to  infection  of  the  cyst.  Tapping,  which  was  formerly  common,  often 
led  to  infection  of  the  cyst.  Dermoid  cysts  are  especially  prone  to  suppura- 
tion. 

The  symptoms  of  suppuration  of  the  cyst  are  pain,  fever,  tenderness  over 
the  tumor,  rapid  pulse  and  exhaustion  and  emaciation.  If  the  suppurating 
cyst  does  not  speedily  cause  death  by  peritonitis,  it  may  later  rupture  into 
the  intestine  or  bladder  or  vagina.  The  teeth,  hair  and  pieces  of  bone  dis- 
charged in  rare  cases  from  the  urethra  or  rectum  are  usuallj^  due  to  suppura- 
tion of  a  dermoid  cyst. 

5.  Rupture  of  the  cyst  may  be  sudden,  as  from  a  fall  or  blow  or  other  in- 
iuvy,  or  it  may  be  the  result  of  a  gradual  thinning  of  the  cyst  wall.  The  re- 
sult of  rupture  of  the  cyst  depends  on  the  ciuantity  and  quality  of  the  cyst 
contents.  In  unilocular  cysts  with  non-irritating  fluid  the  rupture  may  pro- 
duce no  severe  symptoms.  There  is  some  weakness  and  abdominal  pain  and 
marked  diuresis,  the  patient  sometimes  passing  several  gallons  of  urine  in 
twenty-four  hours.  The  abdomen,  which  was  before  prominent  from  the 
tumor,  becomes  flattened  and  lax.  The  physical  signs  change  from  those  of 
encysted  fluid  to  those  .of  free  fluid  (pages  157  and  162).  The  cyst  may  not 
refill,  and  if  no  infl^ammation  takes  place  the  patient  recovers.  But  this  favor- 
able termination  takes  place  only  in  rare  cases.  In  the  great  majority  of 
cases  of  cyst,  rupture  causes  peritonitis,  which  may  be  very  severe  and  rap- 
idly fatal. 

Rupture  of  a  cyst  is  indicated  by  the  sudden  disappearance  of  the  tumor 
or  marked  diminution  in  its  size,  accompanied  with  evidences  of  free  fluid  in 
the  peritoneal  cavity  and  collapse  of  patient,  and  later  peritonitis  and  death. 


TREATMENT  OF  OVARIAN  CYSTS  831 

6.  Ascites.  A  small  amount  of  ascitic  fluid  may  be  present  with  many  cysts, 
but  a  large  quantity  is  rare  so  long  as  the  tumor  retains  its  normal  condition. 
Consequently  the  presence  of  considerable  ascitic  fluid  with  an  ovarian  cyst 
becomes  of  diagnostic  importance.  The  ascites  may,  of  course,  be  due  to  some 
heart  trouble  or  kidney  trouble  or  liver  trouble,  or  may  be  due  to  peritoneal 
tuberculosis.  xVside  from  such  complications,  ascitic  fluid  is  indicative  of 
some  serious  complications — e.  g.,  a  papillary  cyst,  especially  after  malignant 
change,  or  rupture  of  an  ordinary  cyst. 

7.  Intestinal  Obstruction.  This  may  be  caused  by  direct  pressure  of  the 
tumor  or  by  adhesions  which  contract  and  narrow  the  intestine.  It  is  of 
course  a  very  serious  complication  and  is  indicated  by  the  ordinary  symp- 
toms of  intestinal  obstruction  appearing  in  the  presence  of  an  ovarian  tumor. 

TREATMENT 

of  Ovarian  Cysts. 

The  treatment  of  the  simple  cysts  of  the  ovary  is  symptomatic.  There  is 
no  method  of  atfecting  these  little  cysts  directly  except  by  operation,  and  the 
symptoms  are  usually  not  severe  enough  to  warrant  operation.  Consequently, 
the  treatment  is  directed  toward  relieving  the  symptoms,  and  consists  of  the 
measures  recommended  under  chronic  pelvic  inflammation  for  relieving  the 
same  symptoms.  If  the  symptoms  are  persistent  and  very  troublesome  in 
spite  of  all  minor  measures,  the  abdomen  may  be  opened  and  the  cysts  re- 
moved, saving  as  much  as  possible  of  both  the  ovaries. 

The  treatment  of  the  proliferating  cysts  and  dermoid  cysts  is  removal  by 
operation  as  soon  as  found,  if  the  condition  of  the  patient  will  permit. 

Ovarian  tumors  are  not  at  all  influenced  by  palliative  measures,  they  do 
not  stop  growing  spontaneously  and  they  tend  to  death  within  a  few  years. 
Consequently  they  should  be  removed  as  soon  as  found  or  as  soon  as  the  pa- 
tient can  be  gotten  into  condition  for  the  operation.  Sometimes  the  patient 
is  in  such  a  weakened  condition  that  she  must  be  given  a  course  of  treatment 
before  operation.  Some  general  disease,  such  as  kidney  or  heart  or  lung- 
trouble,  may  make  it  necessary  to  delay  the  operation  until  the  patient  can 
be  put  in  better  condition. 

Then,  again,  the  patient  may  be  in  such  condition  that  a  radical  operation 
would  be  almost  certainly  fatal.  In  such  a  case  it  would  of  course  be  useless 
to  operate.  In  some  such  inoperable  cases  the  patient  may  be  rendered  tem- 
porarily more  comfortable  by  tapping  the  cyst  with  a  trocar  and  draAving  off 
the  fluid.  In  all  cases  of  proliferating  cysts,  however,  in  which  the  patient 
is  in  suitable  condition,  the  tumor  should  be  removed  by  operation. 

SOLID  TUMORS  OF  THE  OVARY. 

Solid  tumors  of  the  ovary  are  rare.  They  comprise  only  about  five  per  cent, 
of  all  ovarian  growths  that  come  to  operation. 

The  simple  tumors  are  fibromata  and  fibromyomata.    These  growths  are 


332  TUMORS  OF  THE  OVARY 

infrequent  and  usually  small,  though  occasionally  one  will  grow  to  weigh 
ten  or  fifteen  pounds. 

Of  the  malignant  growths,  sarcoma  is  said  to  be  the  most  frequent.  It 
may  be  of  the  spindle-cell  or  round-cell  variety,  and  usually  grows  rapidly. 
As  a  rule  both  ovaries  are  affected. 

Carcinoma  of  the  ovary  is  generally  secondary  to  a  papillary  cyst.  Both 
ovaries  are  affected  in  the  majority  of  cases. 

Owing  to  the  rarity  of  solid  tumors  of  the  ovary  and  the  absence  of  dis- 
tinctive symptoms,  the  diagnosis  is  usually  made  only  after  the  abdomen  is 
open. 

In  the  case  of  a  firm  mass-  presenting  the  symptoms  and  signs  already  de- 
scribed for  a  small  ovarian  tumor  (except  fluctuation)  a  probable  diagnosis 
of  solid  tumor  of  the  ovary  may  be  made. 

The  treatment  for  a  solid  tumor  of  the  ovary  is  prompt  removal  by  opera- 
tion. 

TUMORS  OF  THE  PAROVARIUM. 

The  tumors  of  the  parovarium  (broad-ligament  tumors)  are  almost  invaria- 
bly cysts  and  they  are  of  two  kinds,  simple  cysts  and  papillary  cysts. 

The  simple  cysts  are  single  cysts  containing  clear  fluid  resembling  water. 
On  account  of  their  confined  position  they  produce  very  troublesome  symp- 
toms while  still  small.  They  arise  from  various  parts  of  the  remains  of  the 
Wolffian  body  (parovarium,  paroophoron — Figs.  681,  682). 

The  proliferating  papillary  cysts  arise  also  from  the  remnants  of  the 
Wolffian  body  and  their  characteristic  is  the  development  of  papillary 
growths  in  the  interior  of  the  cyst,  which  fill  the  cyst  and  grow  through  its 
wall,  and  spread  to  the  peritoneal  surface  and  the  adjacent  organs  (uterus, 
ovaries,  intestines).  The  whole  pelvis  may  be  filled  with  these  warty  cauli- 
flower growths  and,  having  spread  to  all  the  adjacent  structures,  they  often 
give  rise  to  an  erroneous  diagnosis  of  cancer. 

In  the  majority  of  cases  they  are  bilateral  and  usually  rupture  before  at- 
taining a  large  size.  Though  they  grow  rapidly  and  spread  to  adjacent  organs, 
where  they  implant  themselves  on  the  peritoneal  surfaces  and  grow  freely, 
they  do  not  have  the.  fatal  infiltrating  and  destructive  tendency  of  malig- 
nant disease,  and  many  patients  recover  when  the  abdomen  is  opened  and  the 
larger  part  of  the  growth  removed.  Later  they  may  undergo  malignant 
change,  and  then  they  present  the  usual  characteristics  of  carcinomata. 

These  proliferating  papillary  cysts  arise  from  the  parovarium.  As  most 
parovarian  tubules  lie  in  the  broad  ligament,  the  papillary  cysts  are  usually 
broad  ligament  cysts.  But  they  may  also  arise  from  that  part  of  the  paro- 
varium which  is  prolonged  into  the  hilum  of  the  ovary.  It  is  from  that  loca- 
tion tliat  the  papillary  cysts  of  the  ovary  arise.  As  mentioned  before,  the 
papillary  cysts  of  the  ovary  are  usually  bilateral  and  present  all  the  charac- 
teristics of  the  broad  ligament  papillary  cysts,  except  that  they  arise  from  the 
ovary  instead  of  from  the  broad  ligament.  They  are  supposed  to  arise  from 
the  remnants  of  Wolffian  tubuks  lying  in  the  medullary  portion  of  the  ovary. 


DIAGNOSIS  OF  PAROVARIAN  TUMORS  g33 

Symptoms  and  Diagnosis. 

In  the  clinical  history  and  in  the  signs  obtained  by  examination,  broad 
ligament  tumors  resemble  ovarian  tumors  very  closely.  Practically  the  same 
symptoms  and  signs  which  serve  to  distinguish  an  ovarian  tumor  from  other 
diseases  serve,  also,  to  distinguish  a  broad  ligament  tumor  from  the  same 
diseases.  So  that  as  a  rule,  in  this  condition,  when  there  is  trouble  in  diag- 
nosis, the  difficulty  is  to  tell  whether  the  tumor  present  is  a  broad  ligament 
tumor  or  an  ovarian  tumor. 

The  characteristics  of  the  ordinary  parovarian  cyst,  or  ''broad  ligament 
cysts,"  as  they  are  usually  called,  are  as  follows: 

1.  They  grow  into  the  broad  ligament,  separating  its  layers  and  displacing 
the  adjacent  organs.  The  uterus  is  pushed  far  to  one  side  (Figs.  699,  700, 
388)  and  the  tube  is  usually  stretched  over  the  cyst,  being  much  lengthened 
and  flattened.    The  ovary  also  is  flattened  out  on  the  surface  of    the  cyst. 


■^    xN 


■::?l 


'■ ..-^ _  Periton. 


^ 


^ 


Fig.  699.     A  Parovarian  Cyst  (broad  ligament  cyst)  of  the  left  side.     Notice  liow  it  separates  the  layers  of 
the  broad  ligament  and  also  displaces  the  uterus.     (Kelly— Operaii'^e  Gynecology.) 


There  is  more  or  less  fixation  of  the  cyst  and  also  of  the  displaced  uterus. 
They  may  grow  under  the  peritoneum  and  separate  it  from  the  rectum,  blad- 
der and  abdominal  wall. 

2.  They  produce  serious  symptoms  much  earlier  than  ovarian  cysts.    This 
is  due  to  their  being  confined  within  the  broad  ligament  and  the  pelvis,  and 
■   hence  making  serious  pressure  on  surrounding  organs  while  they  are  still 
,   small.    For  this  reason  they  cause  more  pelvic  pain  and  more  menstrual  dis- 
turbance than  ovarian  cysts  of  the  same  size. 

The  papillary  cyst,  after  rupture  and  spread  of  its  papillary  growths,  may 
produce  a  clinical  picture  very  much  resembling  tubercular  peritonitis  or 
chronic  pelvic  inflammation.  It  then  usually  gives  rise  to  marked  ascites, 
and  the  fluid  returns  repeatedly  after  tapping. 


834 


TUMORS  OF  THE  PAROVARIUM 


The  rapidity  of  growth  of  broad  ligament  tumors  depends  somewhat  on 
the  character  of  the  growth.  Those  of  slow  growth  are  usually  simple  cysts. 
The  papillary  cysts  grow  rapidly  at  the  last,  though  the  growth  may  be  slow 
while  confined  within  the  broad  ligament. 


Fig.  700.  Large  Broad  Ligament  Cyst,  shosving  the  stretching  of  the  Fallopian  tube  and  the  displacement 
of  the  uterus. 

Treatment. 

Tlie  treatment  for  Ijroad  ligament  tumors  is  the  same  as  for  ovarian  tu- 
mors— that  is,  removal  by  abdominal  section.  In  some  cases  of  simple  cyst, 
very  low  in  the  pelvis,  with  the  pati(!nt  in  bad  condition,  it  is  better  to  open 
the  cyst  from  below,  drain  away  tlic  fluid  and  pack  the  cavity,  keeping  the 
wound  open  until  the  cavity  is  obliterated,  the  same  as  in  the  treatment  of 


TREATMENT  835 

pelvic  abscess.    Some  cases  may  be  permauently  cured  in  this  way  with  much, 
less  danger  than  by  abdominal  section. 

Ordinarily,  however,  the  preferable  operation  is  abdominal  section.  The 
operation  for  a  parovarian  cyst  is  somewhat  more  difficult  than  for  an  ova- 
rian cyst  owing  to  the  fact  that  the  parovarian  growth  lies  between  the 
layers  of  the  broad  ligament.  This  necessitates  opening  the  broad  ligament 
to  extract  the  cyst  and  also  necessitates  careful  closure  of  the  remaining 
broad  ligament  cavity  to  prevent  oozing  or  secondary  hemorrhage. 


836 


CHAPTER  XIII. 

MALFORMATIONS. 

Malformations  are  caused  by  errors  in  development.  The  growth  of  an  or- 
gan may  be  simply  arrested  or  it  may  grow  in  the  wrong  way.  In  either 
case  there  results  a  malformation.  Most  genital  deformities  are  due  to  par- 
tial arrest  of  development.  To  understand  these  malformations,  it  is  neces- 
sary to  understand  something  about  the  development  of  the  organs. 

POINTS  IN  DEVELOPMENT. 

The  first  structures  indicative  of  the  genito-urinary  organs  are  the  Wolffian 
ducts,  which  appear  in  the  embryo  at  about  the  fifteenth  day,  and  the 
Wolffian  bodies,  which  appear  the  eighteenth  day.  These  structures  rep- 
resent the  future  kidneys  and  genital  apparatus.  They  lie  on  either  side  of 
the  median  line. 

During  the  fourth  week  another  duct  appears  near  the  Wolffian  body  of 
each  side.  These  are  the  Mullerian  ducts.  The  Wolffian  ducts  go  to  form  the 
excretory  ducts  of  the  genital  apparatus  in  the  male.  The  Mullerian  ducts  go 
to  form  the  excretory  ducts  of  the  genital  apparatus  in  the  female.  A  part 
of  the  Wolffian  body  of  each  side  finally  forms  the  genital  gland  of  that  side — 
i.  e.,  the  ovary  in  the  female  and  the  testicle  in  the  male. 

At  the  end  of  the  first  month  the  middle  part  of  each  Wolffian  body  shows 
thickening  and  proliferation,  resulting  in  the  formation  of  elevated  bands 
called  "genital  ridges."  These  are  the  earliest  traces  of  the  genital  glands. 
For  a  few  days  they  remain  indifferent.  Very  soon,  however,  a  difference  in 
the  two  sexes  is  noticed.  The  primitive  female  gland  "possesses  a  large  num- 
ber of  the  primitive  sexual  cells  and  evidences  a  tendency  of  its  elements  to 
arrange  themselves  into  groups,  in  which  the  large  primitive  ova  become  cen- 
tral figures."  The  primitive  male  gland,  on  the  other  hand,  shows  a  tendency 
to  the  formation  of  a  net-work  of  cell  cords — the  forerunners  of  the  semi- 
niferous tubules.  "]\Iicroscopical  examination  of  the  sexual  primitive  glands 
even  at  the  end  of  the  fifth  week  is  capable  of  distinguishing  the  future  sex 
of  the  being."  In  a  short  time  there  is  a  difference  in  the  gross  appearance  of 
the  gland,  with  a  difference  in  the  arrangement  of  the  ducts. 

The  parts  played  by  the  Wolffian  ducts  and  IMiillerian  ducts  differ  in  the 
two  sexes.  In  the  female  the  IMiillerian  ducts  are  the  most  important.  The 
lower  portions  of  the  ducts  of  Miiller  become  fused  and  form  the  vagina  and 
uterus,  and  the  upper  portions  remain  separated  and  form  the  Fallopian 
tubes  (Figs.  701,  702,  704).  The  lower  end  of  the  canal  (future  vagina) 
formed  by  the  fused  Mullerian  tubes  is  closed  at  first.    Later  the  lower  part 


POINTS   IN   DEVELOPMENT 


837 


of  the  septum,  which  shuts  off  this  canal  from  the  urogenital  sinus,  breaks 
down,  permitting  the  canal  (vagina)  to  communicate  Avitli  the  urogenital  sinus. 
If  this  septum  fails  to  break  down,  imperforate  hymen  results  (Figs.  226,  227). 


fimbria. 


Genital  process 
[penis  or  clitoris). 


Genital 
folds. 


Labium 
iiiinor. 


Bartholin's 
Hand. 


Fig.  701.  Diagram  Representing  the  In- 
different Stage  in  the  Development  of  the 
Generative  Organs.  (Piersol,  after  Thomp- 
son— American  Text-hook  of  Obstetrics.) 


Labium 
major. 

Fig.  702.  Diagram  Illustrating  the  Changes  that  take 
place  in  the  Development  of  the  Female  Generative  Or- 
gans. (Piersol,  after  Thompson — American  Text-hook  of 
Ohstetrics.) 


The  very  end  of  the  other  extremity  of  the  Miillerian  duct  is  usually  repre- 
sented by  a  miniature  cyst  attached  to  one  of  the  fimbrian  and  called  the 
** hydatid  of  Morgagni"  (Fig.  682). 

E/:ididymis. 

Hydatid. i^^,    . 

— y^^fx^^  "  P^^,.adtdymtS>. 

IS  aierramf 


Fig.  703.     Diagram  Illustrating  the  Changes  that  Take  Place  in  the  Development  of  the  Male  Generative 
Organs.     (Piersol,  after  Thompson — American  Text-book  of  Obstetrics.) 


MALFORMATIONS 

The  Wolffian  body  forms  the  ovary  and  also  contributes  the  transverse 
tubules  of  the  parovarium.  The  upper  part  of  the  Wolffian  duct  remains 
as  the  ''head  tube"  of  the  parovarium  (Fig.  682).  The  lower  part  of  the 
Wolffian  duct  sometimes  remains  in  whole  or  in  part,  and  is  then  known  as 
"Gartner's   duct"    (Fig.   682).     These  parovarium  tubules   are   all   atrophic 


Fig.  704.  Diagrammatic  Representation  of  the  Development  and  Malformations  of  the  Uterus.  1,  Show- 
ing the  difTerent  stages  in  the  vmion  of  the  MuUerian  ducts  to  form  the  uterus  and  vagina  and  Fallopian  tubes. 
2,  Uterus  unicornis.  3,  Uterus  bicornis.  4,  Uterus  septus.  5,  Uterus  duplex.  (Gilliam — Practical  Gynecol- 
ogy.) 

structures  of  but  little    importance.     The    ovary    is    the    important    organ 
formed  from  the  WolfKan  body  in  the  female. 

In  the  male  the  Wolffian  tubules  and  Wolffian  duct  contribute  the  im- 
portant system  of  excretory  tubes  represented  by  the  vas  deferens  and  the 


POINTS  IN  DEVELOPMENT 


839 


epididymis,  while  the  IMullorian  duct  is  atrophic,  its  ends  alone  remaining. 
Its  outer  end  forms  the  "hydatid  of  ^Morgagni,"  closely  connected  with  the 
epididymis,  and  its  inner  end  forms  the  "sinus  pocularis,"  or  "uterus  mas- 
culinis,"  opening  into  the  prostatic  portion  of  the  urethra  (Figs.  701,  703). 


at 


gr 

--9f 
---99 


A 


Vag 


p 


i^"'    """w^i^ 


B 


Fig.  705.  Development  of  the  External  Genitals  (after  Ecker-ZieKler  models).  A,  indifferent  stage  (eighth 
week);  gt,  genital  tubercle;  gr,  genital  ridge;  gf,  genital  fold;  z's,  genital  groove.  B,  female  type;  cl, clitoris; 
1.  maj.,  labia  majora;  v,  vestibule;  1.  rain,  labia  minora;  vag,  vagina;  p.  [perineum.  C,  male  type;  gp,  glans 
penis;  pr,  prepuce;  r,  raphe;  s,  scrotum. 

External  Genitals  (Fig.  705).  "Until  the  ninth  or  tenth  week  the  ex- 
ternal genitalia  afford  no  positive  information  as  to  sex" — they  are  indiffer- 
ent. They  then  begin  to  differ  and  "usually  by  the  end  of  the  third  month 
the  external  sexual  organs  are  characteristic  beyond  doubt."   Up  to  the  sixth 


§40  MALFORMATIONS 

week  the  external  opening  of  the  intestine  and  of  the  urinary  apparatus  are 
received  within  a  common  cloacal  recess  whose  recto-uro-genital  orifice  is 
surmounted  by  a  small  conical  elevation,  the  "genital  tubercle."  The  lower 
and  posterior  surface  of  the  genital  tubercle  is  divided  by  a  furrow— the 
"genital  groove" — bounded  by  thickened  edges  called  the  "genital  folds." 
Gradually  a  septum  develops,  separating  the  rectal  opening  from  the  genito- 
urinary opening.  The  "genital  tubercle"  forms  the  clitoris  and  the  "genital 
folds"  form  the  labia. 

The  vestibule  is  formed  by  the  cloaca  or  common  opening  of  the  intestinal 
tract  and  urinary  tract  in  the  early  embryo.  The  perineum,  developing,  sep- 
arates the  rectum  from  this  common  vestibule.  And  the  septum  (hymen) 
closing  the  end  of  the  rudimentary  vagina  (fused  Miillerian  ducts)  breaks, 
allowing  the  vagina  to  open  into  the  vestibule.  This  opening  through  the 
septum  varies  much  in  size,  shape  and  situation,  giving  the  various  forms 
of  opening  found  in  the  hymen  (Fig.  209).  It  is  usually  small,  and  roughly 
crescentie  in  shape. 

The  vagina  is  formed  by  the  fusion  of  the  lower  portions  of  the  two  Miil- 
lerian ducts  and  the  absorption  of  the  longitudinal  septum  between  the 
cavities.  The  uterus  is  formed  by  the  fusion  of  the  middle  portions  of 
the  two  Miillerian  ducts  and  the  absorption  of  the  septum  between  the  cav- 
ities. The  Fallopian  tube  of  each  side  is  formed  by  the  upper  portion  of 
the  Miillerian  duct  of  that  side.  The  ovary  of  each  side  is  formed  from  a 
portion  of  the  "Wolffian  body  of  that  side.  The  parovarium  consists  of  the 
"transverse  tubules,"  which  are  formed  from  the  AVolffian  body,  and  the 
"head  tube,"  which  is  formed  from  the  Wolffian  duct.  The  paroophoron, 
lying  in  the  broad  ligament  near  the  parovarium,  is  the  atrophic  remains 
of  the  lower  segment  of  the  Wolffian  body. 

ANOMALIES  OF  DEVELOPMENT. 

The  more  common  anomalies  of  development  are  as  follows: 

1.  The  septum  between  the  embryonic  vagina  and  the  sinus  uro-genitalis 
may  fail  to  break  down,  in  which  case  there  results  imperforate  hymen  (Figs. 
226,  227). 

2.  ]\Iore  rarely,  perfect  canalization  does  not  take  place  in  the  fused  ]\Iiil- 
lerian  cords  (each  of  which  develops  a  central  canal  and  becomes  a  Miil- 
lerian duct),  resulting  in  a  closed  place  at  some  point  in  the  canal,  giving 
atresia  of  vagina  or  atresia  of  cervix  (Figs.  381,  390).  In  very  rare  cases 
all  of  the  lower  part  of  the  fused  cords  fails  of  canalization,  causing  absence 
of  vagina  (Fig.  229).    ' 

3.  The  septum  which  normally  separates  the  urinary  tract  (urethra)  from 
the  vagina  may  be  defective,  forming  the  anomaly  known  as  hypospadias. 

4.  The  septum  between  the  two  fused  Miillerian  duets  may  persist  all  the 
way  to  the  hymen,  in  which  case  there  exists  double  vagina  (Figs.  230,  231). 

5.  The  septum  may  persist  into  the  uterine  portion  of  the  J\Iiillerian  tract, 
forming  a  uterus  septus  (Fig.  704 J. 


I 


IMPERFORATE  HYMEN  841 

6.  The  middle  portions  of  the  IMiillerian  ducts  may  fail  to  fuse,  giving  a 
doiible  uterus  (uterus  didelphys)   (Fig.  104., ). 

7.  They  may  fuse  only  imperfectly,  giving  a  uterus  with  rudimentary 
horns.  There  may  be  either  two  well-marked  horns  (uterus  bicornis)  (Fig. 
704.,),  or  a  fairly  well-developed  uterus  with  one  rudimentary  horn  (Figs. 
704,,  409). 

8.  The  Wolffian  duct  may  persist  to  some  extent,  giving  a  duct  lying 
alongside  the  vagina  called  Gartner's  duct  (Figs.  681,  682).  This  may  extend 
all  the  way  along  the  vagina  and  open  near  the  hymen,  or  there  may  be  only 
remnants  of  the  tube  here  and  there.  These  remnants  sometimes  develop  so 
as  to  form  small  vaginal  cysts.  Such  cysts  are  situated  in  the  vaginal  wall 
along  the  course  of  the  atrophic  Wolffian  duct. 

The  above  are  the  principal  gross  developmental  anomalies  ordinarily  met 
with.  There  are  many  other  rarer  anomalies,  of  which  lack  of  space  prevents 
mention.  These  vary  in  each  organ  all  the  way  from  slight  modification  to 
complete  absence.  The  ovary  is  probably  the  least  frequently  affected  by 
anomalies,  and  yet,  as  rare  as  they  are,  they  have  produced  many  surprises 
in  abdominal  work.  I  refer  especially  to  the  pregnancies  following  the  sup- 
posed complete  removal  of  both  ovaries.  This  means  of  course  that  some 
ovarian  tissue  remains,  and  it  is  usually  said  to  be  a  ''third  ovary."  While 
the  development  of  three  normal  ovaries  is  not  impossible,  the  condition 
present  in  the  cases  under  consideration  is,  as  a  rule,  ''lobulation"  of  the 
ovary  of  one  or  both  sides,  and  not  the  presence  of  a  complete  third  ovary. 
The  lobulated  ovary  may  show  only  a  marked  constriction,  or  it  may  be 
divided  into  two  or  three  or  many  separate  lobules,  with  considerable  space 
between  various  lobules.  Bovee  mentions  a  case  of  his  which  the  ovary 
of  each  side  was  represented  simply  by  numerous  small  particles  of  ovarian 
tissue  scattered  over  a  large  area  of  the  posterior  surface  of  the  broad  liga- 
ment, and  resembling  verrucal  excrescences.  It  is  evident  that  in  such  a 
case  some  outlying  nodules  of  various  tissue  would  almost  certainly  be 
missed,  especially  if  obscured  by  an  inflammatory  exudate. 

The  malformations  most  commonly  requiring  treatment   are: 

Imperforate   Hymen. 
Atresia  of  Vagina. 
Double  Vagina. 
Malformations  of  Uterus. 
Pseudo-hermaphro  ditism. 

IMPERFORATE  HYMEN. 

The  origin  of  this  malformation  has  just  been  explained.  The  condition 
causes  no  disturbance  until  puberty.  After  puberty  there  is  a  collection  of 
menstrual  blood  back  of  the  imperforate  hymen.  This  gradually  increases 
in  amount  and  distends  the  vagina.    If  the  obstruction  is  not  relieved,  there 


342  MALFORMATIONS 

is  gradual  dilatation  of  the  uterus  (Fig.  227)  and  even  of  the  Fallopian  tubes 
(Fig.  228),  forming  a  cystic  mass,  the  contents  of  which  is  blood  and  the  walls 
of  which  are  formed  by  the  vagina  and  uterus. 

The  symptoms  are  characteristic.  At  the  age  of  puberty  no  menstruation 
appears,  but  about  every  four  weeks  the  patient  has  a  spell  of  feeling  ill,  with 
pain  in  the  lower  abdomen  and  the  usual  disturbances  accompanying  menstru- 
ation. The  mother  supposes  that  the  girl  is  going  to  menstruate,  but  there 
is  no  flow.  This  is  repeated  month  after  month.  As  the  collection  of  blood 
increases,  the  pain  and  disturbance  become  more  marked,  the  patient's  health 
begins  to  sutfer,  and  a  tender  mass  appears  in  the  lower  abdomen.  Finally 
the  patient  becomes  so  sick  that  the  physician  makes  a  local  examination. 
He  finds  that  there  is  no  vaginal  opening  (Fig.  226),  but  instead  there  is  a 
fluctuating  mass  occupying  the  position  of  the  vagina  and  uterus  (Figs. 
227,  228). 

The  treatment  is  crucial  incision  of  the  distended  hymen,  and,  if  the  mem- 
brane is  thick,  excision  of  the  most  of  it.  The  cavity  above  should  be  washed 
out  with  normal  saline  solution  and  then  packed  with  sterile  gauze.  Great 
care  is  necessary  to  prevent  infection.  The  decomposing  blood  that  necessar- 
ily remains  along  the  walls  of  the  cavity  favors  the  rapid  growth  of  pus 
germs,  and,  though  the  operation  is  a  simple  one,  patients  have  died  from  it, 
or  rather  from  the  infection  following. 

ATRESIA  OF  VAGINA. 

The  method  of  origin  of  this  malformation  has  been  explained.  The  con- 
dition may  vary  all  the  way  from  a  thin  septum  blocking  the  canal  to  complete 
absence  of  the  canal.  The  external  genitals  and  hymen  may  be  normal.  On 
making  the  vaginal  examination,  an  obstruction  is  met  with  at  some  point 
in  the  vagina.  If  there  is  a  collection  of  menstrual  blood  back  of  the  septum, 
fluctuation  may  be  detected.  Digital  examination  per  rectum  will  give  some 
idea  of  the  extent  of  the  atresia  and  the  amount  of  blood  behind  it.  If  the 
patient  is  well  past  the  age  of  puberty,  and  there  is  no  fluid  above  the  atresia, 
the  probability  is  that  the  uterus  is  anomalous,  so  much  so  that  menstruation 
could  not  come  on  even  though  the  obstruction  in  the  vagina  were  removed. 
So,  before  undertaking  an  operation  for  making  a  vaginal  canal,  recto-abdom- 
inal examination,  under  anesthesia  if  necessary,  should  be  made  to  establish 
the  size,  shape  and  probable  development  of  the  uterus.  In  cases  of  apparent 
absence  of  the  uterus,  recto-vesical  examination  (see  page  95)  may  be  of  as- 
sistance in  locating  a  small  nodule  in  the  situation  of  the  uterus. 

The  treatment  depends  on  the  circumstances  of  the  case.  If  only  a  tliin 
septum  is  present,  it  sliould  be  treated  practically  the  same  as  an  imperforate 
hymen— i.  e.,  incised,  to  let  out  the  blood,  and  then  partially  or  wholly  ex- 
cised. If  a  considerable  proportion  or  the  Avhole  of  the  vaginal  canal  is 
missing,  the  treatment  requires  extended  operative  measures  according  to 
the  special  conditions  present.  It  may  be  necessary  to  build  up  nearly  a 
whole  new  vagina. 


DOUBLE  VAGINA  84S 

Acquired  Atresia.  A  considerable  proportion  of  the  cases  of  marked 
stenosis  of  the  vagina,  amounting  ahnost  to  atresia,  are  acquired.  Such  a 
condition  may  result  from  injuries  in  childhood  or  inflammation,  par- 
ticularly the  gonorrhoeal  vaginitis  of  childhood,  and  severe  inflammations 
following  the  exanthemata.  Congenital  syphilis  also  may  cause  the  same, 
following  severe  ulceration.  In  later  life,  scar-tissue  resulting  from  injuries 
in  labor  is  the  most  frequent  cause  of  narrowings  in  the  canal  and  bands, 
and  constrictions  and  distortions.  Other  causes  in  the  adult  are  syphilitic 
ulceration,  injuries  and  severe  destructive  inflammations.  A  pessary  left 
in  the  vagina  for  several  years  may  lead  to  such  a  result.  In  rare  cases 
even  complete  atresia  may  result  from  some  one  of  these  causes.  The  at- 
rophic vaginitis  or  "adhesive  vaginitis''  of  old  age  (senile  vaginitis)  leads  to 
adhesion  of  the  walls  of  the  vagina  and  stenosis  and  partial  obliteration  of 
the  canal  (see  page  417).  The  treatment  for  acquired  steno.sis  or  atresia 
of  the  vagina  is  practically  the  same  as  for  the  congenital.  The  acquired 
form,  however,  is,  when  extensive,  likely  to  be  more  difficult  of  satisfactory 
treatment  on  account  of  the  large  amount  of  scar-tissue  in  the  vicinity. 

DOUBLE  VAGINA. 

This  consists  usually  simply  in  a  longitudinal  septum  dividing  the  vagina 
into  tw^o  canals  (septate  vagina).  The  vagina  with  entirely  separate  walls  is  a 
much  rarer  condition.  The  longitudinal  septum  is  the  persisting  fused  wall  of 
the  two  Miillerian  ducts,  as  already  pointed  out.  It  may  extend  the  whole 
length  of  the  vagina,  giving  two  openings  at  the  vestibule,  and  half  the 
cervix  in  each  upper  end  (Figs.  230,  231).  On  the  other  hand,  it  may  con- 
sist simply  in  a  septum  extending  part  way.  Even  when  the  septum  extends 
the  full  length  of  the  vagina,  one  canal  is  usually  so  much  smaller  than  the 
other  and  placed  so  far  to  one  side  that  it  does  not  interfere  with  coitus  or 
pregnancy.  In  fact  the  opening  of  one  canal  may  be  so  flattened  out  at  the 
side  of  an  apparently  normal  vaginal  opening  that  it  is  not  noticeable  except 
on  very  close  inspection.  In  such  a  case,  however,  when  the  slit  beside  the 
vaginal  opening  is  noticed,  further  examination  may  reveal  a  rudimentary 
canal  of  considerable  size,  sometimes  almost  as  large  as  the  patulous  one  (see 
page  185).  At  the  upper  part  of  each  vagina  is  one-half  of  the  cer^-ix.  When 
labor  takes  place  in  a  case  of  double  vaginal  canal,  the  septum  is  likely  to  be 
torn,  partially  or  completely,  converting  the  two  canals  into  one.  Portions 
of  the  septum  may  remain  as  a  partial  septum  at  the  upper  part  of  the  vagina 
or  as  irregular  bands  and  tags.  I  recall  one  case  of  septate  vagina  and  uterus 
seen  in  the  first  pregnancy.  The  patient  passed  through  labor  without  par- 
ticular incident,  except  that  the  cervix  (half  cervix)  was  very  slow  in  dilat- 
ing. The  lower  part  of  the  vaginal  septum  near  the  vaginal  entrance  was 
torn,  but  the  greater  part  remained  and  seemed  to  occasion  no  trouble. 
Later,  the  patient  returned  to  the  hospital  \ATith  gonorrhoea  affecting  the 
vaginal  and  uterine  cavity  of  each  side.  Still  later,  I  was  obliged  to  curet 
both  uterine  cavities. 


g44  MALFORMATIONS 

The  treatment  of  double  vagina  is  simple.  If  the  septum  is  causing  any 
obstruction  or  disturbance,  it  is  divided  or,  better  still,  largely  excised,  so 
that  the  two  vaginal  canals  are  converted  into  one. 

MALFORMATIONS  OF  THE  UTERUS. 

Double  Uterus.  The  malformation  may  consist  of  simply  a  partial  or  com- 
plete septum  in  an  otherwise  normal  uterus  (uterus  septate.  Figs.  704^,  372), 
or  a  rudimentary  horn  with  a  nearly  normal  uterus  (Fig.  409),  or  a  uterus 
with  a  body  divided  into  two  horns  (uterus  bicornis,  Fig.  7043),  or  a  double 
uterus,  with  the  body  and  cervix  of  one  side  separate  from  the  body  and 
cervix  of  the  other  side  (uterus  didelphys,  Fig.  704^),  or  a  "unicorn  uterus" — 
i.  e.,  uterus  made  up  of  the  Mtillerian  duct  of  one  side  only,  the  other  being 
absent  or  nearly  so  (Fig.  704^.  The  most  severe  grades  of  deformity  are 
very  rare,  though  they  are  to  be  thought  of  in  the  diagnosis  in  puzzling 
eases.  A  septum  in  an  otherwise  normal  uterus  is  discovered  only  by  intra- 
uterine manipulation,  such  as  curetment  or  the  introduction  of  the  hand 
after  labor  for  the  removal  of  adherent  placenta  or  for  other  reason. 

No  treatment  for  double  uterus  is  required  ordinarily,  with  the  exception 
of  the  precaution,  when  curetting  the  uterus,  to  be  certain  that  both  cavities 
are  clear.  It  is  appreciated,  of  course,  that  in  this  connection,  and  also 
in  double  uterus,  pregnancy  may  take  place  in  each  of  the  two  cavities,  and 
at  different  times,  producing  various  surprising  results. 

Rudimentary  Horn.  The  uterine  malformation  of  most  practical  interest 
is  that  of  a  rudimentary  horn  with  an  otherwise  nearly  normal  uterus.  This 
is  not  so  very  infrequent  and  many  are  the  diagnostic  difficulties  that  re- 
sult therefrom.  Such  a  rudimentary  horn  extends  outward  from  the  main 
body  of  the  uterus,  and  receives  at  its  outer  extremity  the  attachment  of  the 
Fallopian  tube  and  round  ligament  of  that  side.  The  point  of  attachment  of 
the  round  ligament  is,  in  some  cases,  the  only  decisive  gross  evidence  as  to 
whether  the  mass  in  question  is  an  enlarged  Fallopian  tube  or  a  rudimentary 
horn  of  the  uterus.  The  cavity  of  the  rudimentary  horn  may  be  complete, 
extending  all  the  way  from  the  Fallopian  tube  to  the  main  cavity  of  the 
uterus,  or  it  may  be  only  partial,  being  absent  at  some  part  (Fig.  409),  or  the 
cavity  may  be  entirely  absent,  the  horn  existing  merely  as  a  musculo-tibrous 
cord  connecting  the  Fallopian  tube  and  round  ligament  with  the  uterus. 
Most  of  the  trouble  resulting  from  a  rudimentary  horn  comes  from  infection 
in  it  or  pregnancy  in  it  (Figs.  408,  409). 

The  symptoms  and  diJBFerential  diagnosis  and  treatment  are  the  same  as  for 
similar  affections  of  the  Fallopian  tube,  with  the  following  special  points : 

1.  The  mass  is  usually  connected  to  the  uterus  by  a  much  broader  at- 
tachment. 

2.  There  is  more  enlargement  of  the  uterus  and  distortion  of  its  cavity. 

3.  The  mass  may  become  much  larger  without  rupture  (if  pregnant)  or 
without  adhesions   (if  inflammatory). 

4.  There  may  be  a  communication  with  the  main  uterine  cavity.    In  most 


PSEUDO-HERMAPHRODITISM  845 

cases  the  condition  is  not  thought  of  until  found  during  the  course  of  an 
operation  for  what  -was  supposed  to  be  some  one  of  the  more  common  affec- 
tions. Even  "when  thought  of,  a  diagnosis  is  rarely  possible  (except  in  an 
examination  under  anesthesia),  for  it  produces  the  symptoms  and  signs  of 
more  common  conditions,  and  the  trouble  is  naturally  supposed  to  be  some 
one  of  these  more  common  affections.  In  some  cases,  however,  there  are 
anomalous  symptoms  or  signs  that  make  diagnosis  difficult  and  doubtful, 
and  arouse  suspicion  of  this  malformation.  Sometimes  there  is  decided 
resemblance  to  a  fibroid.  I  recall  one  such  case.  The  symptoms  and  signs 
were  anomalous  and  puzzling.  I  made  a  diagnosis  of  probable  fibroid  \vith 
complications.  Operation  revealed  a  rudimentary  uterine  horn,  with  the 
remains  of  an  early  pregnancy  in  it.     There  was  no  fibroid. 

PSEUDO-HERMAPHRODITISM. 

A  true  hermaphrodite  is,  according  to  Ahf eld's  definition,  "an  individual 
with  functionating  active  glands  of  both  sexes,  provided  with  excretory 
ducts."  No  such  case  has  been  reported  in  which  the  diagnosis  has  been 
fully  accepted,  though  there  is  considerable  dispute  among  authorities  con- 
cerning some.  Several  cases  have  been  recorded  in  which,  among  other 
anomalies,  there  were  glands  that  on  microscopic  examination  presented  some 
of  the  characteristics  of  both  ovary  and  testicle.  But  that  condition  does  not 
constitute  a  double  set  of  glands  and  excretory  ducts. 

A  pseudo-hermaphrodite  is  an  individual  of  one  sex  presenting  some  of  the 
local  characteristics  of  the  other  sex.  Many  such  cases  have  been  recorded 
and  not  a  few  of  them  have  presented  a  most  difficult  problem  in  regard  to 
the  diagnosis  of  the  sex.  The  individual  himself  (or  herself,  as  the  case 
may  be)  does  not  seem  to  be  able  to  help  much  in  determining  the  real 
sex  in  the  most  difficult  cases.  Neugebauer  was  able  to  collect  942  cases 
of  pseudo-hermaphroditism.  In  at  least  41  of  the  pseudo-hermaphrodites  the 
true  sex  was  positively  determined  only  after  abdominal  section,  though  in 
only  four  eases  was  the  operation  undertaken  specifically  for  diagnostic  pur- 
poses. Numerous  cases  are  recorded  where  the  individual  dressed  and  lived 
for  many  years  as  a  man  or  as  a  woman,  and  then  ascertained  that  the  real 
sex  was  the  opposite  one.  The  most  celebrated  ease,  perhaps,  is  that  of  Carl 
Hohmann,  a  masculine  pseudo-hermaphrodite,  who  from  infancy  to  the  age 
of  forty-six  years  was  considered  a  female  and  lived  as  such.  The  true  sex 
being  then  ascertained,  he  assumed  male  attire  and  married  as  a  man.  The 
space  available  is  not  sufficient  to  permit  the  subject  of  pseudo-hermaphodit- 
ism  to  be  taken  up  in  an  extended  way.  It  is  sufficient  to  mention  some  of 
the  more  practical  points. 

When  a  child  presents  any  anomaly  of  the  genital  organs,  a  most  careful 
examination  should  be  made  and  all  the  possibilities  considered,  in  order 
to  determine  positively  the  real  sex.  Steps  in  the  development  of  the  external 
genitals  are  shoAvn  in  Fig.  705.  Most  of  the  pseudo-hermaphrodites  are  really 
males  (have  testicles  in  the  abdomen  or  scrotum),  the  resemblance  to  the  fe- 


846 


MALFORMATIONS 


male  external  genitals  being  due  to  some  form  of  hypospadias  accompanied 
with  an  abnormal  opening  or  pocket  that  is  mistaken  for  a  vagina  (Figs.  706, 
707).  The  principal  anomaly  in  female  pseudo-hermaphrodites,  that  causes 
some  resemblance  to  the  male  sexual  organs,  is  hypertrophy  of  the  clitoris 
(Fig.  269),  accompanied  with  adhesion  of  the  labia  minora  or  labia  majora 
over  the  vaginal  opening  (Fig.  225),  or  with  imperforate  hymen  (Fig.  226), 
or  with  labial  hernia  (Fig.  281),  or  hydrocele  or  other  labial  swelling  covering 
the  vestibule. 


Fig.  70G.  MalePseudo-herniaphroditism.  The 
appearance  of  the  external  genitals  in  marked 
hypospadias. 


Fig.  707.  A  section  explanatory  of  Fig.  706. 
B,  bladder;  R,  rectum;  P,  penis  with  lower 
urethral  wall  absent ;  H,  abnormal  condition 
constituting  hypospadias  and  requiring  a  care- 
ful examination  to  determine  the  sex  of  the 
child ;  X,  sinus  pocularis,  enlarged  and  open- 
ing on  perineum,  and  consequently  likely  to 
be  mistaken  in  the  new-born  for  a  vagina. 


In  some  eases  the  positive  determination  of  the  sex  is  very  difficult  and 
may  even  be  impossible  except  by  abdominal  section.  The  general  rule  in 
cases  of  doubt  is  to  class  the  pseudo-hermaphrodite  as  a  male  until  unmistak- 
able evidence  of  the  opposite  sex  appears.  This  will  avoid  a  mistake  in  the 
great  majority  of  instances.  In  the  case  of  four  supposed  female  pseudo- 
hermaphrodites who  were  subjected  to  abdominal  section,  three  of  them  proved 
to  be  males. 


847 


CHAPTER  XIV. 

DISTURBANCES  OF  FUNCTION. 

I  shall  consider  here  not  only  those  disturbances  which  we  designate  as 
"functional"  because  no  organic  lesion  is  apparent,  but  also  those  disturb- 
ances of  function  due  to  various  organic  diseases — that  is,  I  shall  consider  all 
"disturbances  of  function,"  whether  accompanied  by  evident  organic  disease 
or  not.  These  conditions  are,  of  course,  only  symptoms.  They  are  not  dis- 
eases and  must  not  be  taken  to  constitute  a  diagnosis.  They  are  only  indi- 
cations of  some  disease,  and  the  physician  must  determine  the  nature  of  that 
disease  by  further  investigation. 

The  subjects  will  be  taken  up  as  follows: 

Disturbances  of  Menstruation. 

Points  in  Physiology  (Normal  Menstruation). 
Absence  of  Menstruation  (Amenorrhoea). 
Scanty  Menstruation. 
Excessive  Menstruation  (Menorrhagia). 
Painful  Menstruation  (Dysmenorrhoea). 
Irregular  Menstruation. 
Precocious  Menstruation. 
Vicarious  Menstruation. 

Disturbances  of  Sexual  Intercourse. 

Dyspareunia. 
Sexual  Impotence. 

Disturbances  of  Child-bearing. 

Sterility. 

Discharge  from  the  Genitals. 

Leucorrhoea. 
Bloody  Discharge. 

POINTS   IN   PHYSIOLOGY  (NORMAL   MENSTRUATION). 

As  a  prelude  to  the  menstrual  disturbances  proper,  it  is  well  to  call  at- 
tention to  some  points  in  the  physiology  of  normal  menstruation. 

Menstruation  is  the  regular  periodic  discharge  of  blood  from  the  uterus, 


848  DISTURBANCES  OF  FUNCTION 

recurring  about  every  four  weeks  from  puberty  to  the  menopause,  except 
during  pregnancy  and  lactation.  This  definition,  however,  does  not  express 
all  there  is  of  menstruation.  The  menstrual  flow  is  simply  the  outward  sign 
of  important  internal  changes,  and  we  must  inquire  what  these  internal 
changes  are  and  what  they  mean  in  the  life  of  the  woman. 

In  dealing  with  this  subject  there  must  be  taken  into  consideration  the  fol- 
lowing three  phenomena : 

Puberty  and  the  beginning  of  menstruation. 

Menstruation  when  fully  established. 

The  menopause  or  "change  of  life." 

1.  Puberty  and  the  Beginning  of  Menstruation.  Puberty  is  the  period  at 
which  the  girl  matures  and  becomes  capable  of  child-bearing.  This  period 
is  marked  by  a  very  rapid  development  of  the  sexual  organs.  The  ovaries, 
uterus,  vagina  and  external  genitals  enlarge,  hair  appears  in  the  pubic  region 
and  in  the  axillae,  the  breasts  become  more  prominent,  the  pelvis  enlarges 
and  the  whole  body  becomes  somewhat  larger  and  its  outlines  more  rounded 
and  graceful.  These  physical  changes  are  accompanied  by  mental  changes, 
which  are  indicated  by  modesty,  sexual  desire  and  allied  phenomena. 

These  changes  take  place  usually  between  the  eleventh  and  sixteenth  years. 
When  the  proper  development  has  been  reached,  the  menstrual  flow  appears. 
This  flow  is  the  sign  that  development  has  taken  place  and  that  ovulation  has 
begun.  Ovulation,  no  doubt,  occurs  before  menstruation  appears,  sometimes 
long  before,  but,  as  the  menstrual  flow  is  the  outward  sign  of  the  internal 
sexual  preparation,  the  period  of  sexual  activity  is  counted  as  beginning 
with  the  first  menstrual  flow. 

The  age  at  which  the  first  menstruation  appears  varies  in  different  races 
and  under  different  environment.  Climate  has  long  been  thought  to  in- 
fluence the  beginning  of  menstruation — the  colder  the  climate  the  later  the 
first  menstruation.  This  holds  good  as  a  general  rule,  the  Laplander  begin- 
ning to  menstruate  at  about  18,  while  the  inhabitant  of  hot  climates  at  from 
9  to  11.  Englemann  has  shown,  however,  that  in  some  of  the  most  northerly 
tribes  menstruation  appears  as  early  as  in  the  tropics.  The  mode  of  life  has 
some  influence,  as  has  also  the  general  health  of  the  girl.  Girls  raised  in  the 
city  begin  to  menstruate  earlier,  usually,  than  those  raised  in  the  country.  In 
addition  there  are  the  personal  inherited  tendencies,  about  which  we  know 
very  little,  but  which  exercises  a  marked  influence  on  the  phenomena  of  life. 

Occasionally  the  beginning  of  menstruation  is  long  delayed  without  any 
apparent  cause.  Hirst  had  a  patient  who  menstruated  for  the  first  time  at 
the  age  of  33,  had  four  periods  in  the  next  two  years,  and  then  conceived 
two  months  later.  He  records  also  a  reported  case  of  a  woman,  married  at 
34,  who  menstruated  for  the  first  time  at  the  age  of  45,  and  bore  a  child  at  46. 

In  the  United  States  a  girl  is  expected  to  begin  to  menstruate  when  she  is 
twelve  or  thirteen  or  fourteen.  Not  infrequently  the  menstrual  flow  begins 
at  the  age  of  ten  or  eleven,  and  hence  M^hen  a  girl  reaches  about  the  age  of 
ten  her  mother  should  explain  to  her  that  a  slight  bloody  floAv  may  be  ex- 


POINTS  IN  PHYSIOLOGY  849 

pected  and  that  it  is  nothing  that  need  frighten  or  worry  her,  but  entirely 
natural. 

The  period  of  puberty  is  sacred  to  the  physical  development  of  the  girl. 
During  these  years  (i.  e.,  from  the  age  of  10  to  that  of  16)  she  should  live  in 
a  free  and  healthful  way — plenty  of  fresh  air  and  outdoor  exercise,  with 
proper  rest  at  menstrual  periods,  an  abundance  of  plain  nourishing  food, 
regular  hours  of  sleep,  only  a  moderate  amount  of  school  work  and  other 
mental  training — in  short,  a  regimen  that  favors  free  physical  development, 
unhampered  by  exhausting  mental  work  or  by  indolent  habits.  Some  of  the 
distressing  disturbances,  pelvic  and  otherwise,  that  appear  later  in  life  are 
due  to,  or  increased  by,  neglect  at  this  developmental  period.  Girls  are  per- 
mitted to  rise  late  and  sit  around  the  house,  doing  little  else  than  read,  when 
they  should  be  at  some  healthful  physical  work  (house-work,  outdoor  exer- 
cise, etc.),  or,  on  the  other  hand,  they  are  given  exhausting  school  studies, 
immoderate  piano  practice,  and  other  acquisitions  of  modern  life  that  keep 
the  body  too  much  indoors  and  in  one  posture,  and  that  develop  mental  ac- 
tivity at  the  expense  of  physical  strength. 

2.  Ordinary  Menstruation.  The  phenomenon  is  known  under  a  variety  of 
names — for  example,  "menses,"  "monthly  sickness,"  "monthly  period," 
"monthlies,"  "periods,"  "regular  sickness,"  "catamenia. "  Patients  usually 
refer  to  their  menstruation  as  the  time  when  they  were  "unwell." 

The  menstrual  flow  is  accompanied  by  certain  changes  in  the  endometrium, 
already  described  (page  528).  These  consist  principally  of  engorgement  and 
swelling  of  the  endometrium,  hemorrhagic  infiltration  and  the  casting  off  of 
cells  over  small  areas.  Gebhard  has  demonstrated  conclusively  that  there  is 
no  wholesale  destruction  of  the  endometrium,  as  was  formerly  taught.  There 
are  also  some  changes  in  the  general  assimilative  and  excretory  proc- 
esses of  the  body.  The  amount  of  urea  excreted  is  diminished,  the  appetite 
is  poor,  and  there  is  usually  more  or  less  aching  and  lassitude. 

The  menstrual  discharge  consists  of  blood  mixed  with  secretion  and  epi- 
thelium from  the  uterus  and  with  epithelium  from  the  vagina.  This  admix- 
ture with  mucus  and  epithelium  takes  place  to  such  an  extent  by  the  time 
the  vagina  is  reached  that  the  blood  does  not  clot.  It  is  dark  and  rather 
viscid  or  stringy  from  its  admixture  with  cervical  mucus.  The  menstrual 
discharge  has  also  some  odor,  due  to  slight  decomposition,  which  takes 
place  during  its  passage  through  the  vagina.  Menstrual  blood  taken  directly 
from  the  interior  of  the  uterus  has  no  odor  and  it  clots  like  ordinary  blood. 

The  amount  of  blood  lost  at  each  menstruation  varies  greatly  in  different 
individuals,  the  usual  amount  being  probably  from  five  to  ten  ounces.  The 
rate  of  flow — i.  e.,  whether  or  not  the  flow  is  too  free — is  estimated  usually  by 
the  freciuency  with  which  the  napkins  have  to  be  changed.  The  usual  flow  re- 
quires a  change  about  three  times  daily  during  the  height  of  the  menstrua- 
tion.  If  more  frequent  changing  is  necessary,  the  flow  is  too  free. 

There  is  considerable  variation  in  the  duration  of  the  menstrual  flow,  the 
average  being  three  to  four  days.    Some  perfectly  healthy  women,  however, 


g50  DISTURBANCES  OF  FUNCTION 

menstruate  only  one  or  two  days  and  others  six  to  seven  days.  T^.e  seai  -y 
menstruation  or  the  profuse  menstruation,  as  the  case  may  be,  seems  to  be 
normal  for  that  particular  individual.  The  duration  of  the  flow  in  t>3  same 
individual  is  usually  about  the  same  at  the  different  periods. 

The  periodicity  of  the  flow  is  more  uniform,  the  flow  recurring  about  every 
28  days.  However,  many  healthy  women  menstruate  at  periods  somewhat 
longer  or  shorter  than  this.  In  one  series  the  duration  from  beginning  to  be- 
ginning was  28  days  in  70  per  cent  of  the  cases,  30  days  in  13.7  per  cent,  27 
days  in  1.4  per  cent,  and  21  days  in  1.6  per  cent  (Krieger). 

Menstruation  ceases  during  pregnancy  and  lactation.  Exceptions  to  this 
rule  are  frequent.  A  few  women  menstruate  for  one  or  two  periods  after  con- 
ception, and  very  often  the  menses  return  while  a  woman  is  still  nursing  her 
child. 

The  principal  physiological,  significance  of  menstruation  is  that  it  is  a  prepa- 
ration of  the  uterus  for  the  reception  of  a  fertilized  ovum.  As  to  the  exact 
significance  of  each  step  in  the  menstrual  process,  and  as  to  whether  it  has 
to  do  with  other  important  functions  (eliminative),  there  is  still  much  dispute. 
The  old  conception  of  menstruation  as  a  general  cleansing  process  has  long 
since  disappeared,  but  recently  some  interesting  arguments  have  been  put 
forth  to  show  that  menstruation  assists  in  the  elimination  of  the  supposed 
ovarian  "internal  secretion." 

The  hygiene  of  the  menstrual  period  is  the  same  as  the  hygiene  of  any  other 
period,  except  that  there  should  be  a  little  less  physical  and  mental  strain. 
Even  when  menstruation  is  perfectly  normal,  there  is  usually  some  feeling  of 
general  discomfort  and  a  disinclination  to  extra  physical  or  mental  exertion, 
and  this  feeling  should  be  favored  in  so  far  as  it  does  not  interfere  with  the 
general  healthful  routine  of  life.  Exercise,  tepid  bathing,  an  abundance  of 
sleep,  regular  meals  and  nourishing  food  are  all  as  necessary  at  this  time 
as  at  any  other. 

3.  Menopause.  In  a  healthy  woman  menstruation  ceases  at  the  age  of  44  to 
47.  There  is  considerable  variation  in  this  respect,  the  menses  sometimes 
ceasing  three  or  four  years  before  that  age  or  continuing  three  or  four  years 
afterward.  It  is  very  exceptional,  however,  for  menstruation  to  cease  before 
forty  or  to  continue  after  fifty.  This  period  of  cessation  of  menstruation  is 
known  variously  as  the  ''menopause,"  the  "climacteric,"  and  the  "change  of 
life."  The  changes  that  take  place  in  the  uterus  during  and  after  the  meno- 
pause have  already  been  described  (page  528).  They  are  similar  to  those  oc- 
curring in  all  the  genital  structures — namely,  a  gradual  atrophy  of  the  func- 
tionating part  (endometrium  and  muscular  tissue),  a  general  fibrous  change 
and  a  slow,  but  decided,  diminution  in  size. 

The  menses  usually  cease  gradually — that  is,  the  flow  may  be  less  free  or  may 
continue  a  shorter  time  than  usual,  or  the  flow  may  be  missed  entirely  for  one 
or  two  periods.  This  partial  and  irregular  absence  of  the  menstrual  flow,  may 
continue  for  one  or  two  or  three  years  before  it  ceases  entirely.  This  o-radual 
diminution  of  the  menstrual  flow  is  natural  and  there  are  frequently  slight 


AMENORRHOEA  851 

neivons  JiSturbanGes  ("hot  flashes,"  etc.)  that  can  hardly  he  classed  as  patho- 
logical. But  many  of  the  symptoms  that  rre  ordinarily  considered  as  part  of 
the  "change  of  life"  are  really  not  so — for  example,  increased  menstrual  flow, 
bloody  discharge  between  the  menstrual  periods,  leucorrhoea,  pelvic  pain,  and 
marked  nervous  disturbances.  These  are  due  to  pathological  conditions.  They 
mean  that  something  is  wrong,  and  they  require  investigation,  that  the 
trouble  may  be  remedied.  This  is  important  especially  in  the  case  of  vaginal 
discharge,  whether  bloody  or  leucorrhoeal.  It  seems  to  be  the  general  im- 
pression among  women  that  irregular  bloody  discharges  are  natural  during 
the  "change  of  life."  But  such  discharges  are  not  natural — they  usually  mean 
either  inflammation  or  cancer.  One  of  the  saddest  things  in  gynecological  work 
is  that  a  large  proportion  of  the  cases  of  cancer  of  the  uterus  are  beyond  the 
possibility  of  a  cure  when  first  examined.  In  such  a  case  it  is  supposed  by  the 
patient  and  her  friends  that  the  slight  bloody  discharge  which  at  first  ap- 
pears is  "natural  to  the  change  of  life,"  and  so  no  attention  is  paid  to  it. 
Later,  too  late,  they  find  that  it  is  due  to  serious  disease,  which,  because  of  neg- 
lect, has  progressed  to  such  an  extent  that  it  is  beyond  cure. 

ABSENCE  OF  MENSTRUATION  (AMENORRHOEA). 

Amenorrhoea  is  the  absence  of  menstruation  for  one  or  more  periods  be- 
tween puberty  and  the  menopause.  You  will  notice  that  the  definition  includes 
the  absence  of  the  menses  from  pregnancy  and  lactation.  This  is  known  as 
"physiological  amenorrhoea." 

Pregnancy  must  always  be  taken  into  consideration  in  a  case  of  amenor- 
rhoea, and  before  the  amenorrhoea  is  attributed  to  any  other  cause  pregnancy 
must  be  eliminated — by  the  circumstances  of  the  case  or  by  questioning  the 
patient  or  by  an  examination. 

Amenorrhoea  from  other  causes  is  found  principally  in  girls  and  young 
women  in  whom  the  function  of  menstruation  has  not  yet  been  completely  es- 
tablished. The  age  of  puberty — i.  e.,  the  beginning  of  menstruation — varies 
within  normal  limits  considerably.  Girls  begin  to  menstruate,  as  a  rule,  at  the 
age  of  twelve  or  thirteen  or  fourteen.  The  beginning  of  menstruation  may  be 
postponed  until  the  age  of  16  or  17  without  disturbance.  Usually,  however, 
after  the  age  of  16,  and  often  before  that,  if  the  menstrual  flow  does  not  ap- 
pear, there  are  disturbances  that  indicate  some  departure  from  normal  health, 
and  the  patient  may  be  said  to  have  amenorrhoea. 

Amenorrhoea  is  not  a  disease,  but  only  a  symptom.  It  may  be  an  indication 
of  any  one  of  several  entirely  distinct  conditions,  just  as  a  cough  may  be  an 
indication  of  laryngitis  or  bronchitis,  or  pneumonia  or  tuberculosis.  When 
a  patient  comes  complaining  that  she  does  not  menstruate,  the  first  thing  to 
do  is  to  determine  why  she  does  not  menstruate — i.  e.,  what  disease  or  condi- 
tion lies  back  of  this  symptom. 

In  practice  it  is  convenient,  for  purposes  of  diagnosis  and  treatment,  to  di- 
vide the  cases  of  amenorrhoea  into  two  classes — one  class  including  those 


352  DISTURBANCES  OF  FUNCTION 

patients  who  have  never  menstruated  and  the  other  class  including  those 
who  have. 

(A.)     WHEN  THE  PATIENT  HAS  NEVER  MENSTRUATED. 

A  mother  brings  her  daughter,  aged  15  or  16  or  perhaps  18,  to  you,  stating 
that  the  girl  has  never  come  unwell.  The  mother  is  anxious  to  know  why  the 
girl  does  not  come  unwell  and,  of  course,  what  should  be  done  for  her. 

Causes. 

In  such  a  case  the  absence  of  menstruation  may  be  due  to  one  of  three 
causes,  as  follows: 

1.  Poor  general  health,  with  pronounced  anemia. 

2.  Some  obstruction  in  the  genital  canal. 

3.  Imperfect  development  of  the  uterus. 

"Which  of  the  causes  is  present  in  this  particular  patient?  That  you  must 
find  out  by  investigation,  and  the  first  step  in  that  investigation  is  to  deter- 
mine the  state  of  the  patient's  general  health.  Is  she  pale,  weak,  lacking  in 
vigor,  always  tired,  easily  exhausted  by  light  work  ?  If  so,  the  amenorrhoea  is 
probably  due  to  the  first  cause  mentioned. 

1.  Poor  General  Health,  with  Pronounced  Anemia.  The  next  step  is  to  search 
carefully  for  the  cause  of  the  poor  vitality,  with  its  resulting  anemia.  The 
mother  usually  thinks  the  poor  health  is  due  to  the  absence  of  the  menses, 
while  the  fact  is  that  the  absence  of  the  menses  is  due  to  the  poor  health,  and 
the  poor  health  is  due  to  some  general  or  local  disease,  the  nature  of  which  it 
is  your  province  to  ascertain. 

Now,  it  would  be  out  of  place  here  to  attempt  to  take  up  in  detail  the  differ- 
ential diagnosis  of  all  the  diseases  which  may  cause  deterioration  of  the  gen- 
eral health,  with  marked  anemia  and  amenorrhoea.  All  I  can  do  is  simply  to 
point  out  some  of  the  common  causes. 

a.  Tuberculosis  is  a  very  frequent  cause  of  amenorrhoea.  It  may  appear  in 
the  form  of  tuberculosis  of  the  lungs,  or  of  the  intestines  or  of  the  peritoneum, 
or  of  the  glands  or  of  the  bones,  or  of  the  urinary  organs — any  of  the  various 
forms  of  tuberculosis.  The  proper  questions  must  be  asked  to  elicit  the  in- 
formation necessary  to  establish  the  presence  or  absence  of  this  disease. 

b.  iMalaria,  particularly  in  the  chronic  form,  is  a  frequent  cause  of  anemia 
in  malarial  regions. 

c.  Acute  disease,  such  as  typhoid  fever,  pneumonia,  diphtheria,  and  the 
exanthemata  occurring  at  puberty,  may  Aveaken  the  patient  so  much  as  to 
delay  the  beginning  of  menstruation  for  many  months. 

d.  Heart  disease  following  rheuiiialisni  in  cliildhood  may  cause  persistent 
and  severe  disturbances  of  nutrition. 

e.  Digestive  disturl)ances  or  kidney  lesion,  or  diseases  of  the  ner\ous  sys- 
tem, may  cause  a  depression  of  vitality  to  such  an  extent  that  the  patient  does 
not  menstruate. 


AMENORRHOEA  853 

f.  Confinement  indoors,  exhausting  studies,  overwork,  poor  food,  lack  of 
exercise — any  of  these  things  may  cause  anemia  with  amenorrhoea. 

g.  Chlorosis.  In  some  cases  we  can  find  no  definite  local  or  general  disease 
to  account  for  the  blood  condition — the  pronounced  anemia.  In  this  class 
come  the  cases  of  chlorosis,  and  of  pernicious  anemia  and  of  the  other  so- 
called  "pinmary"  anemias.  The  differential  diagnosis  of  these  forms  of 
anemia  l)elongs  to  general  medicine,  and  the  diagnostic  points  are  described 
under  diseases  of  the  blood.  Chlorosis  occurs  so  frequently  in  girls  and  young 
women  that  it  is  sometimes  classed  as  a  gynecological  affection,  but  it  belongs 
to  general  medicine  the  same  as  the  other  blood  diseases. 

Suppose,  however,  that  our  patient  is  not  anemic,  but  is  rosy,  robust  and 
apparently  in  good  general  health.     What  then  causes  the  anemia? 

2.  It  may  be  due  to  some  obstruction  in  the  genital  canal.  The  obstruction 
is  due  to  some  malformation,  such  as  imperforate  hymen,  or  atresia  of  vagina 
or  atresia  of  cervix  uteri.  These  malformations  are  rare,  the  most  frequent 
being  imperforate  hymen  (page  841). 

Obstruction  in  the  genital  canal  gives  rise  to  no  symptoms  until  puberty 
is  reached.  At  the  age  of  13  or  14  or  later  the  patient  begins  to  feel  very 
bad  each  month.  At  intervals  of  about  four  weeks  she  notices  marked  lassi- 
tude and  loss  of  appetite,  feels  somewhat  feverish  and  out  of  sorts,  has  pain 
in  various  parts  of  the  body,  more  particularly  in  the  back  and  lower  abdo- 
ment.  She  complains  just  as  a  woman  does  when  she  is  about  to  be  unwell. 
Her  mother  thinks  she  is  coming  unwell,  but  no  flow  appears.  After  a  few 
days  the  pain  and  other  disturbing  symptoms  subside  and  she  feels  fairly  well 
until  the  next  month. 

After  several  months  the  pain  and  accompanying  disturbances  last  longer — 
in  fact,  may  become  almost  continuous — and  the  patient's  general  health  be- 
gins to  suffer.  A  swelling  may  appear  in  the  lower  abdomen  or  at  the  vagi- 
nal entrance. 

Such  a  history  makes  a  local  examination  imperative.  In  the  local  exami- 
nation, if  the  condition  be  imperforate  hymen,  the  vaginal  entrance  is  found 
closed.  There  may  be  a  bulging  of  the  hymen  due  to  the  pressure  of  menstrual 
blood  behind  it.  If  the  atresia  is  situated  high  in  the  vagina,  the  vaginal  en- 
trance is  found  open,  but  after  the  examining  finger  has  been  introduced  for 
a  short  distance  it  meets  an  obstruction,  consisting  of  a  wall  of  tissue  block- 
ing the  vagina.  If  there  is  a  collection  of  menstrual  blood  behind  the  obstruc- 
tion fluctuation  may  be  obtained.  Digital  examination  by  the  rectum  will  give 
additional  information  as  to  the  location  and  length  of  the  vaginal  atresia  and 
as  to  the  amount  of  menstrual  fluid  collected  behind  it.  In  long-standing 
cases  the  vagina  and  uterus  and  even  the  Fallopian  tubes  may  be  distended 
with  blood. 

In  cases  of  atresia  of  the  vagina  there  are  very  liable  to  be  other  malforma- 
tions higher,  and  sometimes  the  uterus  is  entirely  absent.  If  the  patient  is  past 
the  age  of  puberty  and  no  collection  of  blood  is  found  above  the  vagina! 


g54  DISTURBANCES  OF  FUNCTION 

atresia,  the  strong  probability  is  that  the  uterus  and  appendages  are  either 
absent  or  so  poorly  developed  that  menstruation  would  be  impossible  even 
though  the  vaginal  obstruction  were  removed.  Careful  examination  should 
be  made  to  determine  certainly  whether  or  not  the  uterus  is  present. 

But  suppose  the  girl  is  healthy— good  color,  good  general  health,  and  no 
local  malformation — what  then  causes  the  amenorrhoea? 

3.  It  may  be  due  to  imperfect  development  of  the  uterus.  This  poor  devel- 
ment  of  the  uterus  may  be  simply  part  of  a  general  under-development,  or  it 
may  be  limited  to  the  uterus  and  appendages,  the  patient  being  otherwise 
strong  and  fully  developed. 

In  some  cases  the  imperfect  development  is  so  marked  that  it  can  be  proven 
by  examination  (body  of  uterus  very  small).  In  other  cases  the  imperfec- 
tion is  less  marked — the  uterus  and  appendages  are  apparently  normal,  as 
far  as  can  be  determined  by  ordinary  bimanual  palpation,  and  still  the  de- 
velopment has  stopped  short  of  perfection,  as  is  shown  by  the  fact  that  the 
patient  does  not  menstruate  and  that  treatment  directed  toward  stimulating 
development  brings  on  the  menstrual  flow. 

Treatment. 

The  patients  now  under  consideration  are  girls  and  young  women  who  have 
never  menstruated.  If  there  are  no  marked  local  symptoms  pointing  to  ob- 
struction, the  first  step  in  treatment  is  to  put  the  patient  in  the  best  possible 
general  health.  A  local  examination  is  not  indicated  at  first  in  the  absence 
of  local  symptoms.  The  anemia  should  be  corrected,  and  the  general  health 
improved  and  the  normal  function  stimulated  by  the  following  measures : 

1.  The  long  continued  administration  of  iron,  accompanied  by  arsenic  or 
strychnia  or  other  tonics,  as  indicated  by  the  conditions  present. 

2.  Curtail  exhausting  school  duties,  immoderate  piano  practice  and  other 
acquisitions  of  modern  life  that  keep  the  body  too  much  indoors  and  in  one 
posture,  and  that  develop  mental  activity  at  the  expense  of  physical  strength. 

The  mind  should  be  trained  of  course,  but  it  should  be  trained  in  a  way 
that  does  not  interfere  with  the  development  of  the  body.  The  age  of  puberty 
is  sacred  to  the  physical  development  of  the  girl  and  nothing  should  be  al- 
lowed to  interfere  with  it. 

A  step  in  the  right  direction  is  the  introduction  of  regular  gymnastic  exer- 
cises in  the  curriculum  of  the  public  schools.  This  needs  to  be  extended  and 
combined  Avith  a  certain  ainouni  of  outdoor  exercises. 

The  course «of  study  in  the  public  schools  should  be  under  such  medical 
supervision  1hat  tlic  pupils  be  not  unduly  taxed,  and  when  it  is  seen  that  a 
girl  is  not  doing  well  j)hysically,  her  parents  should  be  advised  to  take  her 
out  for  a  time  and  let  her  live  the  outdoor  life  that  she  needs.  Such  a  step  in 
time  would  turn  many  a  girl  from  the  path  of  imperfect  development  and  life- 
long invalidism,  and  cause  her  to  become  a  healthy,  ro])ust  and  useful  woman — 
an  omament  to  society  and  a  blessing  to  all  around  her. 


AMENORRHOEA  855 

3.  Regular  and  Moderate  Exercise.  There  are  excellent  general  works  on 
the  various  forms  of  exercise,  and  I  would  advise  a  study  of  this  sul)ject,  for, 
in  many  affections,  well-directed  exercise  is  one  of  our  best  remedies.  I  will 
here  speak  of  only  a  few  points. 

a.  Take  five  to  ten  minutes'  exercise  with  a  Whitcly  exerciser,  or  other 
good  exerciser,  each  night  after  the  clothing  is  loosened  for  retiring.  The  ex- 
ercise should  be  taken  regularly — every  night  without  fail.  It  should  be 
moderate  at  first,  not  more  than  five  minutes,  and  the  time  lengthened  as  the 
patient  becomes  used  to  it.  It  should  not  be  violent.  Begin  with  correct 
standing  and  walking  and  then  pass  to  the  arm  movements  and  the  move- 
ments that  involve  the  chest  muscles,  the  expansion  of  the  chest,  etc.  As  the 
patient  gets  used  to  the  work  and  can  extend  the  time,  other  movements  may 
be  taken  up,  movements  involving  the  abdominal  and  back  muscles  and  the 
muscles  of  the  hips  and  lower  extremities.  I  think  it  is  a  good  plan,  however, 
to  always  take  the  arm  movements,  either  at  the  beginning  or  end  of  each 
exercise  period. 

b.  Take  a  walk  of  5  to  10  blocks  (^A  to  %  mile)  each  day.  It  is  best  to 
have  a  regular  time  for  this.  This  exercise  should  be  regular  and  moder- 
ate, and  deep  breathing  should  be  remembered  (a  deep  breath  every  8  to  10 
inspirations)  and  correct  easy  position  in  standing  and  walking. 

With  this  as  with  the  indoor  gymnastic  exercise,  it  is  not  the  length  or 
amount  of  exercise  so  much  as  the  regularity  of  it  that  accomplishes  the  de- 
sired result. 

c.  Other  forms  of  outdoor  activity,  such  as  horseback  riding,  driving,  row- 
ing and  the  various  outdoor  sports,  are  excellent,  as  they  keep  the  patient 
out  in  the  open  air  and  sunshine  and  at  the  same  time  necessitate  considerable 
muscular  activity.  They  are  particularly  invigorating  because  they  add  to 
the  necessary  exercise  a  healthful  interest  and  anticipation  and  enjoyment 
But  these  things  should  not  be  allowed  to  interfere  with  the  regular  walk 
and  gymnastic  exercise — in  fact,  at  the  first  regular  gymnastic  exercise  and 
walk  will  probably  be  all  the  patient  can  take  without  fatigue,  and  it  is  only 
after  these  have  been  practiced  for  a  time  that  the  more  active  out-of-door 
sports  can  be  undertaken  without  harmful  fatigue.  These  latter  are  to  be 
taken  only  in  addition  to  the  other  when  the  patient  is  ready,  and  not  in 
place  of  them. 

4.  Regular  Meals  and  Suitable  Food.  An  abundance  of  good  nourishing 
food  should  be  taken  at  regular  intervals.  At  first  the  patient's  appetite 
will  probably  be  capricious  and  she  will  not  care  for  much  substantial  food. 
Do  not  try  to  stuff  her  and  do  not  tell  her  she  must  eat  a  great  deal  of  this 
or  that  article  of  food,  of  which  even  the  thought  perhaps  destroys  what  little 
appetite  she  has.  Eather  give  the  exercise  that  will  after  a  time  give  her  an 
appetite,  and,  after  she  gets  so  she  is  really  hungry,  tell  her  what  article  of  diet 
she  can  not  have,  leaving  her  to  find  her  food  from  the  other  articles  or  go  hun- 
gry. Thus  by  giving  her  an  appetite  and  cutting  off  the  unwholesome  articles 
with  which  she  has  perhaps  been  accustomed  to  pamper  herself,  she  will  soon 


g56  DISTURBANCES  OF  FUNCTION 

be  taking  an  abundance  of  good  substantial  food  and  be  glad  to  get  it.  The  re- 
sult will  be  good  blood,  strong  muscles,  sound  sleep,  graceful  carriage,  healthy 
color,  clear  mind,  sweet  temper  and  a  general  attractiveness  which  can  never 
be  supplied  by  cosmetics  and  indolent  luxury. 

5.  After  the  patient  is  well  started  on  this  regimen,  say  after  one  or  two 
months,  she  may  be  given  some  of  the  emmenagogue  preparations,  provided 
the  menstruation  has  not  already  begun.  In  some  cases  as  soon  as  the  patient 
is  put  in  good  general  health  the  menstruation  begins  normally.  In  other 
cases  the  menstruation  does  not  appear,  even  when  the  patient  has  been  re- 
■  stored  'to  apparently  good  general  health. 

In  such  a  case  the  tonic  regimen  is  continued  and  in  addition  some  em- 
menagogue  preparation  is  given,  such  as  manganese  dioxide,  apiol,  or  some 
of  the  other  preparations  mentioned  under  Formulae. 

If  after  two  or  three  months  of  this  treatment  the  menstrual  flow  does  not 
appear,  or  at  any  time  if  marked  local  symptoms  develop,  make  a  vaginol 
and  bimanual  examination  and  determine  if  there  is  any  obstruction  to  the 
flow  or  any  other  pathological  lesion  needing  correction. 

If  an  obstruction  (imperforate  hymen  or  atresia  of  vagina)  is  found,  it  must 
be  treated  as  described  elsewhere  under  the  organic  lesion. 

If  no  obstruction  is  found  and  the  organs  are  apparently  normal,  it  is  then 
to  be  assumed  that  the  trouble  is  due  to  imperfect  development  of  the  uterus — 
that  is,  that  the  organ  has  stopped  short  of  perfection.  We  then  employ) 
measures  to  stimulate  the  uterus  to  functional  activity. 

The  tonics,  the  exercise,  the  emmenagogues  and  the  other  measures  men- 
tioned tend  in  that  direction.  One  of  the  local  measures  frequently  used  for 
stimulating  a  poorly  developed  uterus  is  electricity  in  its  various  forms,  both 
galvanic  and  faradic. 

If  the  symptoms  recur  at  regular  intervals,  indicating  that  that  is  the  timi: 
that  the  menstrual  flow  is  nearly  taking  place,  use  hot  sitz  baths,  hot  foot 
baths,  and  warm  applications  to  the  lower  abdomen. 

The  propriety  of  intra-vaginal  measures  depends  somewhat  on  the  patient. 
In  some  patients  the  vaginal  opening  is  large  and  the  patient  is  not  particu- 
larly nervous,  and  local  treatmSit  may  be  carried  out  without  special  trouble. 
In  such  a  case  applications  of  silver  nitrate  solution  (4%  to  10%)  to  the  cer- 
vix may  be  made  every  other  day  at  the  time  when  the  precursory  symptoms 
of  menstruation  appear.  The  hot  douche  also  may  be  used  two  or  three  times 
daily.  If  these  are  still  ineffective,  vagino-abdominal  applications  of  elec- 
tricity may  be  tried. 

In  the  case  of  a  patient  who  is  nervous  and  distressed  by  the  local  treat- 
ment, and  particularly  if  the  vaginal  opening  is  very  small,  no  intra-vaginal 
treatment  should  be  employed  without  anesthesia,  except  the  introduction  of 
the  small  vaginal  electrode  or  the  giving  of  hot  vaginal  douches.  In  such  a 
case  no  intra-uterine  treatment  is  used  unless  there  is  some  indication  '  for 
giving  the  patient  an  anesthetic. 

It  may  be  that  an  anesthetic  is  required  to  make  a  careful  examination  to 


AMENORRHOEA  857 

determine  whether  or  not  there  is  any  serious  abnormality  of  the  organs.  In 
such  a  case  it  is  well  to  have  instruments  ready  for  dilating  the  cervix,  as 
that  seems  to  act  as  a  stimulant  to  menstruation  in  these  cases.  In  some  eases 
euretment  is  indicated  as  a  local  stimulant. 

Occasionally  there  is  anteflexion  with  atrophic  endometritis,  and,  if  that  con- 
dition be  present,  the  uterus  had  best  be  curetted  at  the  same  time  that  the 
cervix  is  dilated.  During  this  treatment  under  anaesthesia  the  vaginal  en- 
trance and  cervix  uteri  should  be  well  dilated,  so  that  an  intra-urine  elec- 
trode may  be  used  later,  if  necessary. 

In  a  case  of  amenorrhoea  where  the  girl  is  engaged  to  be  married,  the 
Cjuestion  of  the  propriety  of  marriage  sometimes  comes  up — the  parents  or 
the  patient  desiring  to  know  whether  it  would  be  right  for  her  to  marry 
when  she  has  never  menstruated.  The  answer  is,  that  if  there  is  no  organic 
lesion,  which  in  itself  is  a  bar  to  marriage,  marriage  is  perfectly  proper,  just  the 
same  as  though  the  girl  were  menstruating  regularly.  In  such  a  case  th4 
absence  of  menstruation  is  simply  a  functional  disturbance,  which  will  prob- 
ably soon  disappear  under  the  influence  of  a  happy  married  life. 

(B.)     WHEN  THE  PATIENT  HAS  MENSTRUATED. 

When  the  patient  has  menstruated  one  or  more  times,  the  absence  of  men- 
struation is  due  to  one  of  the  following  causes : 

Causes. 

1.  Some  condition  connected  with  pregnancy. 

2.  Some  other  form  of  physiological  amenorrhoea. 

3.  Poor  general  health,  with  anemia. 

4.  Acute  general  disease. 

5.  Local  (pelvic)   disease. 

6.  Operative  removal  of  essential  structures. 

7.  Obesity.  ."  . 

8.  Nervous  impressions. 

9.  Suppression  of  menses. 

1.  Pregnancy,  a.  Normal  Pregnancy. — If  the  patient  has  previously  been 
regular  in  menstruation,  is  in  good  health  and  has  had  an  opportunity  to  be- 
come pregnant,  the  natural  supposition  is  that  she  is  pregnant,  and  until  it 
is  proven  that  she  is  not  pregnant,  nothing  should  be  done  that  could  in  any 
way  interfere  with  pregnancy. 

The  patient  may  assert  positively  that  she  is  not  pregnant,  may  even  deny 
any  possibility  of  pregnancy,  but  when  after  examination  there  is  any  sus- 
picion in  your  mind,  postpone  all  local  treatment  until  after  the  next  men- 
strual flow.  If  you  doubt  the  patient's  honesty — that  is,  if  you  think  she 
may  return  and  tell  you  that  she  menstruated  when  in  fact  she  did  not — tell 
her  that  she  must  come  during  the  flow,  that  you  may  determine  the  character 


858 


DISTURBANCES  OF  FUNCTION 


of  the  flow.    In  this  way  you  can  establish  certainly  whether  or  not  she  really 

menstruates.  1,1     •    i 

In  this  matter  of  the  question  of  pregnancy  it  requires  considerable  judg- 
ment and  tact  to,  on  the  one  hand,  detect  the  cases  of  pregnancy,  and,  on  the 
other  hand,  avoid  wounding  the  feelings  of  innocent  persons  by  lU-advised 
questions.  Concerning  the  question  of  pregnancy,  the  cases  may  be  divided 
into  three  classes.  In  the  first  class  come  the  girls  and  unmarried  women  in 
which,  from  the  character  of  the  trouble  or  from  the  known  character  of  the 
patient,  the  possibiHty  of  pregnancy  may  be  at  once  eliminated.  These 
correspond  very  closely  with  the  patients  Avho  have  never  menstruated  and 
require  the  same  treatment. 

In  the  second  class  come  the  married  women.  In  these  an  examination  may 
be  made  at  once  and  the  diagnosis  of  pregnancy  settled  thus.  If  the  diag- 
nosis is  still  doubtful  after  examination,  the  patient  is  told  that  it  is  too  early 
yet  to  be  certain  about  it  and  she  is  directed  to  come  again  after  a  month  or 
six  weeks. 

In  the  third  class  come  the  girls  and  unmarried  women  about  whom  you 
know  but  little— they  may  be  all  right  or  they  may  be  all  wrong ;  you  simply 
do  not  know  and  hence  must  be  cautious.  In  this  class  come  also  widows, 
divorced  persons,  women  living  apart  from  their  husbands — all  of  whom,  if 
pregnant,  might  wish  to  conceal  the  fact.  Some  of  these  patients  are  per- 
fectly truthful  with  the  physician,  telling  him  their  fears  or  leaving  a  clear 
opening  for  the  asking  of  questions  that  would  bring  out  the  information.  In 
other  cases  the  patient  gives  the  whole  history  of  her  case  without  any  inti- 
mation of  a  misstep.  Occasionally  the  patient  tries  deliberately  to  deceive 
the  physician,  hoping  that  in  his  examination  or  treatment  something  may  be 
done  that  will  bring  about  an  abortion. 

In  such  uncertain  cases  it  is  usually  best  for  the  physician  to  keep  his 
thoughts  to  himself,  and  not  to  intimate  any  suspicion  of  pregnancy  until 
some  good  evidence  of  it  is  found.  Do  not  depend  too  much  upon  the  history 
the  patient  gives.  Just  keep  in  mind  that  it  may  be  all  truth  and  it  may  be 
all  falsehood.  If  the  patient  is  a  girl  or  unmarried  woman,  an  examination 
need  not  be  made  at  once.  She  may  be  placed  on  tonic  treatment  that  will 
not  interfere  with  pregnancy.  This  will  put  her  in  better  condition  for  men- 
struation and  in  the  meantime  the  case  may  be  observed  and  developments 
watched  for.  If  after  several  weeks  menstruation  does  not  appear,  an  ex- 
amination may  be  suggested..  If  the  patient  was  formerly  married,  or  has 
taken  local  treatment  or  has  had  an  examination  made,  an  examination  may 
be  advisable  at  once.  If  the  examination  signs  are  not  decisive  either  way, 
the  patient  may  be  kept  on  tonic  treatment  and  another  examination  made 
after  several  weeks. 

In  this  way  the  physician  protects  himself  and  at  the  same  time  gives  the 
patient  good  treatment.  If  it  turns  out  that  no  pregnancy  is  present,  the 
patient  need  never  know  that  pregnancy  was  suspected.  On  the  other  hand 
if  it  turns  out  that  pregnancy  is  present,  nothing  has  been  done  that  could 


AMENORRHOEA  859 

possibly  interfere  with  it.  He  has  done  what  was  right  for  the  patient  and 
has  protected  himself,  and  accordingly  prevented  the  patient  from  making 
a  fool  of  him,  as  some  of  the  deluded  "smart"  ones  try  to  do. 

b.  Extra-uterine  Pregnancy. — The  evidences  of  tubal  pregnancy  have 
already  been  given  (page  773). 

1.  Other  Forms  of  Physiological  Amenorrhoea.  a.  Lactation. — As  a  rule, 
a  woman  does  not  menstruate  while  nursing  a  baby.  There  are,  however, 
many  exceptions  to  this  rule,  especially  after  the  first  six  months.  Quite 
frequently  a  patient,  while  nursing  her  child,  Avill  begin  to  menstruate  within 
five  or  six  months  after  labor  and  occasionally  witliin  two  or  three  montlis. 
This  happens  most  freciuently  in  those  cases  in  which  the  mother  has  only 
enough  milk  to  partly  nourish  the  baby. 

b.  Beginning  Menopause. — The  age  at  which  the  menopause  begins  varies 
much  in  different  persons.  The  average  age  is  about  forty-five,  but  it  often 
begins  somewhat  earlier,  in  exceptional  cases  before  forty.  If  the  patient 
is  past  forty  and  the  menstrual  flow  has  been  getting  gradually  less  for  sev- 
eral months,  the  menopause  is  probably  beginning.  There  are  two  separate 
phenomena  that  usually  accompany  the  climacteric  and  that  may  aid  in  the 
diagnosis — the  "hot  flashes"  with  some  irritability  and  other  e^adences  of 
nervousness,  and  the  tendency  to  increase  in  the  subcutaneous  fat  deposit. 
Neither  one  of  these  is  pathognomonic,  but  both  of  them  occurring  in  a  patient 
past  forty,  with  menstruation  gradually  diminishing,  make  the  diagnosis  of 
the  climacteric  fairly  certain. 

3.  Poor  Health,  with  Pronounced  Anaemia.  There  is  poor  blood,  poor  gen- 
eral health  and  want  of  tone,  secondary  to  some  wasting  disease  or  to  chlo- 
rosis. The  cause  is  determined  by  a  careful  general  examination  of  the 
patient,  including,  w^hen  necessary,  examination  of  the  urine  and  of  the 
sputum  and  of  the  blood.  It  is  usually  due  to  some  chronic  disease.  It  may 
come  from  any  of  the  conditions  mentioned  under  anemia  in  patients  who 
have  never  menstruated  (page  852)  or  from  other  troubles  that  reduce  the 
patient's  vitality.  Among  the  latter  may  be  mentioned  prolonged  lactation, 
pregnancies  too  close  together,  close  confinement  indoors  with  housework  or 
children,  and  sameness  of  work  day  after  day  without  stimulating  variety. 

4.  Acute  Disease.  Acute  diseases,  such  as  typhoid  fever,  pneumonia,  the 
exanthemata,  influenza  or  even  a  severe  cold,  may  delay  menstruation  or 
cause  it  to  be  missed  entirely,  particularly  if  the  attack  comes  at  about  the 
menstrual  time.  On  the  other  hand,  the  beginning  of  an  acute  disease  may 
cause  the  menstrual  flow  to  appear  too  soon  or  to  be  too  free. 

5.  Local  (Pelvic)  Disease.  The  local  diseases  that  may  cause  amenorrhoea, 
independent  of  their  general  effect  on  the  blood,  are  those  diseases  that  affect 
the  integrity  of  the  endometrium  (from  which  comes  the  menstrual  blood) 
or  that  affect  the  integrity  of  the  ovaries   (from  which  come  the  menstrual 

impulse). 

a.  Hj^erinvolution  of  Uterus.— The  process  of  involution  following  preg- 
nancy and  labor  may   continue   farther  than  normal,   reducing  the   uterus 


ggO  DISTURBANCES  OF  FUNCTION 

below  normal  size  and  so  modifying  the  endometrium  as  to  interfere  with 
menstruation.  This  is  a  rare  condition,  but  must  be  kept  in  mind  in  consid- 
ering a  case  of  amenorrhoea  in  a  patient  who  has  given  birth  to  a  child  within 
a  year  or  two.  In  one  of  my  cases  the  patient  was  28  years  of  age.  Three 
years  before  she  had  had  a  severe  infection  following  the  birth  of  her 
child  and  there  had  been  no  menstruation  since.  Bimanual  examination 
showed  the  uterus  to  be  very  small.  On  account  of  other  trouble  it  was 
necessary  to  open  the  abdomen,  and  I  had  the  opportunity  of  inspecting  the 
internal  genital  organs.  Everything  was  atropliic — the  uterus,  ovaries,  tubes  . 
and  round  ligaments.  The  uterus  was  about  half  the  normal  size.  Hyper- 
involution  may  occur  also  following  simple  curetment  for  chronic  endometri- 
tis, though  that  is  even  more  rare. 

b.  Cirrhosis  of  the  Uterus. — This  is  the  last  stage  of  chronic  metritis,  that 
stage  in  which  the  wall  of  the  uterus  and  the  endometrium  are  largely  con- 
verted into  scar-tissue.  There  is  loss  of  the  functionating  elements,  marked 
diminution  of  the  blood  supply  and  consequent  cessation  of  function  before 
the  appointed  age. 

c.  Destruction  of  Ovaries  by  Disease. — The  ovaries  furnish  the  menstrual 
impulse,  and  when  they  are  so  damaged  by  disease  that  all  of  the  functuating 
elements  (Graafian  follicles  with  contained  ova)  are  destroyed,  menstruation 
ceases.  This  rarely  happens,  for  even  in  extensive  and  destructive  pelvic 
inflammation,  enough  of  one  ovary  usually  sur^dves  to  continue  menstruation, 
providing  the  patient 's  general  health  is  not  too  much  affected. 

6.  Operative  Removal  of  Structures.  The  structures  essential  to  continu- 
ous regular  menstruation  are  the  uterus  and  some  funtionating  ovarian  tissue. 

a.  Hysterectomy. — The  removal  of  the  uterus  ordinarily  means  cessation 
of  menstruation.  In  certain  cases  of  supravaginal  hysterectomy  for  fibroids, 
sufficient  of  the  lower  part  of  the  corpus  uteri  may  be  preserved  to  continue 
menstruation  (Chapter  XV).  Of  course  such  an  operation  constitutes  only 
a  partial  amputation  of  the  corpus  uteri.  The  removal  of  the  cervix  uteri 
alone  has  practically  no  effect  on  menstruation. 

b.  Double  Oophorectomy. — The  complete  removal  of  both  ovaries  (removal 
of  all  ovarian  tissue  in  the  pelvis)  causes  menstruation  to  cease,  either  at  once 
or  within  a  few  months.  In  many  cases,  even  with  both  ovaries  badly  dam- 
aged, enough  ovarian  tissue  may  be  left  to  continue  menstruation.  In  suit- 
able cases  this  is  the  practice  ordinarily  followed.  To  secure  the  desired 
result,  however,  the  ovarian  tissue  left  must  continue  to  functionate. 

On  the  other  hand,  in  exceptional  cases,  when  both  ovaries  have  supposedly 
been  completely  removed,  the  patient  has  continued  to  menstruate  and  has 
even  become  pregnant.  That  means,  of  course,  that  some  ovarian  tissue  was 
left.  Some  part  of  the  normal-shaped  ovaries  may  have  been  unwittingly 
left  or  there  may  have  been  lobulation  of  one  ovary.  Islands  of  ovarian 
tissue,  from  malformation  of  ovary,  are  occasionally  found  in  the  pelvis,  either 
close  to  the  normal  site  of  the  ovary  or  at  some  distant  part  of  the  broad 
ligament  (page  841). 


AMENORRHOEA  ggj 

The  removal  of  one  ovary  has  little  or  no  effect  on  menstruation,  provided 
the  other  continues  to  functionate.  The  removal  of  one  or  both  Fallopian 
tubes  has  practically  no  eft'ect  on  menstruation. 

7.  Obesity.  The  condition  of  the  system  associated  with  the  excessive 
deposit  of  fat  very  frequently  causes  diminution  in  the  menstrual  flow  and 
may  cause  it  to  cease  altogether  for  a  time.  Tliis  may  occur  with  obesity  in 
girls  as  well  as  in  older  women. 

8.  Nervous  Impressions.  Nervous  impressions  may  delay  or  stop  the  menses 
for  a  few  months,  or  delay  their  appearance  if  occurring  at  puberty.  Among 
these  may  be  mentioned:  a  long  journey  (particularly  on  shipboard),  change 
of  residence  from  country  to  city  or  vice  versa,  extraordinary  grief,  joy,  or 
anxiety,  or  exciting  work,  study  (as  in  prepjaring  for  examination),  taking 
up  a  new  occupation,  financial  troubles,  love  affairs  and  ditHculties  in  home 
life.     Any  of  these  may  cause  an  expected  menstruation  to  be  missed. 

Treatment. 

The  treatment  required  is  indicated  by  the  particular  abnormal  condition 
present.  The  methods  of  treatment  for  the  various  organic  diseases  are 
given  in  the  appropriate  chapters. 

In  anemia  employ  the  course  of  tonic  treatment  followed  by  emmenagogues, 
previously  described  for  anemia  in  patients  who  have  never  menstruated 
(page  854). 

In  married  women,  with  no  decided  organic  lesion,  the  poor  general  health 
may  be  due  to  prolonged  lactation,  to  pregnancies  coming  too  close  together, 
to  the  worry  and  care  of  children,  with,  perhaps,  too  much  housework  besides, 
or  to  too  close  confinement  indoors  with  monotonous  housework.  Close  con- 
finement in  the  house,  with  the  same  round  of  housework  day  after  day  and 
month  after  month,  without  a  diverting  change  of  work  or  a  stimulating  ob- 
ject to  be  attained,  is  enough  to  produce  digestive  disturbance,  malnutrition, 
anemia  and  general  depression,  both  physical  and  mental.  In  the  same  way 
the  woman  who  devotes  her  time  largely  to  society  may,  by  the  constantly 
repeated  round  of  social  exactions,  become  completely  "fagged  out."  Also, 
the  woman  who  does  office  work  may  be  worn  out  by  having  to  do  the  same 
work  day  after  day  for  months  and  years. 

In  all  such  cases,  besides  the  regular  tonic  course,  a  change  or  break  in  the 
regular  routine  is  advisable.  This  change  should  be  a  decided  one.  It 
should  produce  not  only  a  change  in  physical  activity,  but  also  should  change 
the  current  of  thought  and  furnish  a  new  direction  for  mental  activity.  The 
prescription  to  bring  about  these  changes  will  vary  much  in  different  cases, 
depending  to  a  large  extent  on  the  circumstances  and  inclinations  of  the 
patient.  With  some  it  will  be  a  prolonged  trip  abroad,  leisurely  visiting 
places  of  interest;  with  others,  a  trip  to  the  seashore  or  to  the  mountains 
for  a  few  weeks  or  several  months.  In  the  cold,  cloudy  months  of  the  winter 
a  sojourn  in  the  South  may  be  advisable;  while,  to  escape  the  heat  of  sum- 
mer, the  northern  lake  resorts  are  available  in  addition  to  the  mountains 


862  DISTURBANCES  OF  FUNCTION 

and  the  seashore.  *  In  other  cases  a  few  weeks'  rest  in  the  country  will  answer 
the  purpose,  or  a  prolonged  visit  with  friends  in  another  city,  or  the  employ- 
ment of  help,  so  that  the  patient  has  less  routine  housework  or  office  work, 
and  more  time  for  rest,  amusement,  outdoor  exercise  and  some  diverting- 
leisure  pursuit,  such  as  photography,  painting,  music,  fancy  work,  or  one  of 
the  many  other  things  which  furnish  physical  and  mental  diversion.  A 
change  of  thought  and  action  for  a  few  weeks  or  a  few  months,  as  the  case 
may  he,  is  one  of  the  best  tonics,  and,  when  combined  with  suitable  medication 
and  hygiene,  it  may  make  one  "feel  like  a  new  person."  The  regular  work 
can  then  be  taken  up  with  interest  and  pleasure,  and  can  be  executed  with 
vigor  and  satisfaction.  Keep  in  mind,  however,  that,  to  continue  in  good 
health,  the  patient  must  take  time  for  proper  rest,  nourishment,  exercise  and 
relaxation. 

Obesity.  When  the  patient  is  considerably  heavier  than  she  should  be, 
particularly  if  she  has  increased  in  weight  recently,  she  should  be  placed 
on  treatment  for  correcting  the  faulty  metabolism  that  results  in  fat  deposi- 
tion. The  systematic  treatment  of  this  condition  belongs  to  general  medicine 
and  cannot  be  considered  in  detail  here.  I  Avill  say  only  that  I  have  obtained 
good  results  in  these  cases  from  the  granular  effervescent  Vichy  and  Kis- 
singen  salts  given  on  alternate  days — one  day  the  Vichy  and  the  next  day 
the  Kissingen,  etc.  This  should  be  continued  for  two  or  three  months  and 
combined  with  a  more  or  less  strict  diet.  Even  when  the  weight  is  not  notice- 
ably reduced,  the  metabolism  is  improved,  the  patient  is  placed  in  better 
general  health  and  hence  in  better  condition  for  menstruation.  Of  course, 
when  the  stout  patient  is  anemic,  she  requires  a  course  of  iron  along  with  the 
other  treatment. 

When  the  amenorrhoea  is  apparently  due  to  nervous  impressions  (a  long 
journey,  change  of  environment,  grief,  joy,  anxiety),  no  treatment  is  required 
except  for  accompanying  disturbances.  When  the  patient  becomes  accustomed 
to  her  neAv  surrouudiugs,  the  menses  will  probabty  return.  In  the  meantime  any 
symptomatic  disturbance  should  be  treated — a  sedative  if  needed,  a  tonic  if 
indicated,  an  emmenagogue  at  once  if  thought  best,  or  later  if  the  menses 
do  not  appear. 

Supppression  of  the  menses  requires  rather  active  treatment.  First  satisfy 
yourself  tiiat  you  are  not  l)eing  deceived — i.  e.,  that  no  pregnane^''  is  present. 
Then  employ  measures  to  produce  pelvic  congestion  and  to  overcome  the 
nervous  inhijjitory  influence  which  has  been  started  by  exposure  to  cold  or 
nervous  shock,  or  whatever  it  was  that  caused  the  sudden  suppression  of  the 
flow.  If  the  patient  is  very  nervous  or  in  pain,  give  sedatives  in  sufficient 
doses  to  set  the  nerves  at  rest.  Have  the  patient  take  a  warm  sitz  bath  (a 
iiinstard  foot  bath  may  be  given  at  the  same  time),  then  have  her  put  to  bed, 
covered  up  warmly  and  liot  applications  made  to  the  lower  abdomen  and 
genitals.  Hot  drinks,  that  tend  to  start  up  the  secretory  action  of  the  skin 
and  other  organs,  are  tlien  advisa])le.  If  the  bowels  have  not  moved  well, 
direct  a  large  enema  of  warm  water  or  warm  soap  water. 


MENORRHAGIA  863 

As  to  medication,  that  is  largelj^  symptomatic.  In  sudden  suppression  of 
the  menstrual  flow  (from  exposure  to  cold  or  nervous  shock),  accompanied 
by  full  pulse  and  feeling  of  fullness  in  the  head  and  in  the  pelvis,  give  drop 
doses  of  tincture  of  aconite  every  half  hour  until  the  circulatory  tension  is  re- 
lieved. Used  in  conjunction  with  the  measures  above  mentioned,  this  often 
causes  the  flow  to  return  in  a  few  hours.  Tincture  of  Pulsatilla,  given  in  two- 
drop  doses  every  3  hours,  is  sometimes  effective  in  relieving  the  distress  and 
restoring  the  flow.  If  there  is  severe  pain,  the  phenacetin  and  codeine  cap- 
sules (see  Formulae)  may  be  required. 

SCANTY  MENSTRUATION. 

A  diminution  in  the  menstrual  flow,  or  a  too  slight  flow  from  the  beginning 
of  menstruation,  is  caused  by  the  same  condition  that  leads  to  absence  of 
the  menses  (with  the  exception  of  those  obstructive  lesions  that  prevent  the 
escape  of  any  blood),  and  the  treatment  also  is  practically  the  same  (page  854). 

EXCESSIVE  MENSTRUATION  (MENORRHAGIA.) 

The  menstrual  flow  may  be  too  free  or  it  may  last  too  long.  In  either  case 
the  condition  is  known  as  excessive  menstruation  or  menorrhagia.  The  nor- 
mal duration  of  the  flow  and  the  amount  of  blood  lost  varies  much  in  dif- 
ferent patients.  With  each  patient,  however,  the  duration  of  the  menstrual 
flow  and  the  amount  of  blood  lost  is  fairly  constant — that  is,  the  patient 
menstruates  about  the  same  length  of  time  and  loses  about  the  same  amount 
of  blood  at  each  normal  menstruation.  If  there  is  decided  increase  in  the 
amount  or  in  the  duration  of  the  flow,  the  patient  may  be  said  to  menstruate 
excessively,  though  the  same  amount  and  duration  of  the  flow  in  another 
individual  might  be  normal  if  usual  with  her.  Each  patient  is  somewhat  of 
a  law  unto  herself  in  this  respect.  Therefore,  to  make  the  diagnosis  of  ex- 
cessive menstruation,  we  need  to  know  something  of  the  patient's  menstrual 
history. 

CAUSES. 

Excessive  menstruation  is  due  to  those  conditions  which  cause  congestion 
of  the  pelvis,  especially  those  which  cause  congestion  of  the  uterine  mucosa. 
It  may  be  caused  by  any  of  the  following  conditions: 

1.  Simple  Hypertrophic  Endometritis.  This  is  the  usual  cause  of  menor- 
rhagia occurring  in  virgins.  As  explained  in  a  previous  chapter  (page  .583), 
this  form  of  endometritis  is  not  real  inflammation  as  that  teriU  is  ordinarily 
understood,  but  is  simply  a  nutritive  change.  The  causes,  diagnosis  and  treat- 
ment of  simple  endometritis  are  given  on  pages  583  to  586. 

2.  Infected  Endometritis.  Inflammation  of  the  uterus,  ^eiiher  acute  or 
chronic,  tends  to  cause  uterine  congestion  and  consequent  increase  of  the 
menstrual  flow. 


gg4  DISTURBANCES  OP  FUNCTION 

3.  Subinvolution,  without  infection,  is  a  rather  frequent  cause  of  prolonga- 
tion of  the  bloody  lochia  after  child-birth,  and  of  excessive  menstruation 
later. 

4.  Malposition  of  uterus,  particularly  marked  retrodisplacement,  is  likely 
to  cause  excessive  menstruation— in  fact,  this  is  one  of  the  prominent  symp- 
toms in  a  large  proportion  of  the  cases  of  backward  displacement  of  the 
uterus  (page  600). 

5.  Cervical  polypi  may  cause  excessive  menstruation  and  also  bleeding  be- 
tween the  menses.  It  is  surprising  how  much  bleeding  will  be  caused  in  some 
cases  by  one  or  two  small  polypi  in  the  cervix. 

6.  Fibro-myoma  of  uterus  causes  menorrhagia  when  intramural  or  sub- 
mucous. This  excessive  loss  of  blood  during  menstruation  is  one  of  the  promi- 
nent symptoms  of  fibroid  (page  631)  and  is  rarely  absent  in  the  classes  men- 
tioned. 

7.  Cancer  of  Uterus.  IMalignant  disease  of  the  uterus  in  any  form,  whether 
affecting  the  cervix  or  the  corpus  uteri,  is  likely  after  a  time  to  show  extra 
menstrual  bleeding.  In  the  early  stage,  however,  the  bleeding  is  more  likely 
to  appear  as  an  occasional  streak  of  blood  between  the  menses,  noticed  af- 
ter coitus  or  after  extra  walking  or  lifting  (page  670). 

8.  Pelvic  inflammation,  both  acute  and  chronic,  causes  periuterine  and 
uterine  congestion,  with  resulting  excessive  menstruation. 

9.  Ovarian  and  broad  ligament  tumors  interfere  with  the  return  of  blood 
from  the  uterus  and  in  that  way  cause  uterine  congestion,  with  resulting  ex- 
cessive menstruation. 

10.  Obstructive  Diseases.  Diseases  that  interfere  with  the  return  of  blood 
from  the  pelvis,  such  as  heart  disease  with  failing  compensation,  obstructive 
liver  diseases  and  abdominal  tumors,  necessarily  tend  to  uterine  congestion 
and  consequent  menorrhagia. 

Diseases  tliat  cause  frequent  straining  efforts,  such  as  constipation,  chronic 
diarrhoea,  stricture  of  rectum  and  chronic  cystitis,  lead  to  pelvic  congestion 
and  excessive  menstrual  flow. 

11.  Functional  Pelvic  Congestion.  In  some  cases  no  lesion  is  found  on  ex- 
amination and  the  prolonged  menstruation  is  evidently  due  simply  to  func- 
tional pelvic  congestion.  This  functional  pelvic  congestion  may  be  caused  by 
many  conditions,  among  wliicli  are  the  following: 

a.  Work  that  favors  pelvic  congestion,  such  as  standing  for  hours  (as 
clerks  must  do),  or  running  a  sewing  machine  for  hours  (as  is  done  by  the 
seamstress),  or  lifting  and  working  about  the  sick  (as  is  done  by  the  nurse), 
may  lead  to  excessive  menstruation. 

b.  Excessive  or  violent  exercise,  as  is  sometimes  taken  in  the  excitement 
of  outdoor  sports. 

c.  Recent  marriage.  In  \hv.  first  few  months  after  marriage  there  is  fre- 
quently some  increase  in  the  menstrual  flow,  but  ordinarily  it  need  cause 
no  alarm,  for  it  usually  disappears  as  the  pelvic  organs  become  accustomed 
to  the  changed  conditions. 


MENORRHAGIA  865 

It  must  be  kept  in  mind,  also,  that  an  early  abortion  coming  about  the  men- 
strual time,  or  an  early  tubal  pregnancy  with  rupture  or  tubal  abortion  at 
the  menstrual  time,  may  very  closely  resemble  an  ordinary  menprrhagia, 
with  some  extra  pain  and  a  few  blood  clots. 

TREATMENT. 

It  is  convenient  to  divide  the  treatment  into  (A)  treatment  during  the 
flow  and  (B)  treatment  between  the  periods. 

Treatment  During-  the  Plow. 

You  are  called  to  see  a  patient  who  is  menstruating,  the  flow  being  too  free 
or  having  lasted  too  long.  By  questioning  the  patient  it  can  usually  be  de- 
termined certainly  that  it  is  a  regular  menstrual  flow  and  not  bleeding  con- 
nected with  an  early  abortion  or  threatened  abortion,  or  tubal  pregnancy. 
As  the  patient  is  menstruating,  of  course  no  examination  is  made  unless 
there  are  indications  of  serious  trouble.  If  the  questioning  shows  clearly  that 
the  trouble  is  simply  excessive  or  prolonged  menstruation,  the  patient  may 
be  given  some  uterine  astringent  internally. 

1.  Internal  Uterine  Astringents.  Ergot,  in  its  various  forms,  is  one  of  the 
most  reliable  of  the  uterine  hemostatics  for  internal  use.  A  satisfactory  way 
of  administering  it  is  the  ergotin  and  nux  vomica  capsule  (Formulae),  one 
capsule  every  4  to  8  hours.  Or  the  fluid  extract  or  other  preparation  may  be 
given.  Ergot  is  efficient  in  all  forms  of  uterine  bleeding,  except  when  preg- 
nancy is  present.  It  must  never  be  given  when  there  is  a  suspicion  of  preg- 
nancy. 

Another  reliable  uterine  hemostatic  is  stypticin.  It  may  be  given  in  the 
prepared  %  gr.  tablets.  I  usually  order  it  in  i/o  gr.  to  1  gr.  doses  in  combina- 
tion "with  ergotin  in  capsules,  one  capsule  to  be  taken  every  4  to  8  hours,  de- 
pending on  the  amount  necessary  to  control  the  bleeding.  Stypticin  is 
cotarnine  hydrochloride.  Cotarnine  is  derived  from  narcotine,  which  is  a 
product  of  opium.  Stypticin  is  a  yellow  powder  of  very  bitter  taste.  It  is 
conveniently  given  in  capsules,  the  dry  powder  being  placed  directly  in  the 
capsules.  It  is  expensive  to  the  patient,  and,  for  that  reason,  I  freciuently  give 
the  ergotin  capsules  for  the  intermenstrual  period  and  the  stypticin  only 
during  the  flow.  A  later  and  allied  product  is  styptol,  a  combination  of 
cotarnine  with  phthalic  acid.  It  has  about  the  same  action  and  indications 
and  dosage  as  stypticin. 

Hydrastis  is  an  old  remedy  much  used  as  a  uterine  hemostatic.  Its  action  is 
not  so  prompt  and  marked  as  that  of  ergot,  but  is  frequently  more  lasting,  and, 
in  addition,  it  is  an  intestinal  tonic.  Hydrastinine,  an  alkaloid  from  hydrastis 
and  closely  allied  chemically  to  stypticin,  is  frecpiently  used  to  check  menor- 
rhagia.  It  is  expensive,  usually  costing  about  twenty  cents  per  grain.  Cal- 
cium chloride,  also,  is  used  as  an  internal  hemostatic.  Strychnia  and  other 
tonics  tends  to  tone  up  relaxed  muscular  tissue  and  may  thus  diminish 
bleeding. 


866  DISTURBANCES  OF  FUNCTION 

2.  Laxatives.  At  the  beginning  of  the  treatment  the  bowels  should  be 
moved  well  with  a  saline  purgative,  and  after  that  laxatives  should  be  given 
as  needed  to  secure  one  or  two  good  bowel  movements  daily. 

3.  Rest  in  Bed.  The  patient  should  stay  in  bed  during  the  flow  if  possi- 
ble.  If  the  bleeding  is  at  all  severe,  this  is  imperative. 

The  employment  of  the  three  measures  above  mentioned  will  usually  di- 
minish the  flow  decidedly  within  twenty-four  hours. 

4.  Sedatives.  If  the  patient  is  nervous  and  restless  or  if  there  is  dys- 
menorrhoea  (a  very  frequent  accompaniment  of  menorrhagia) ,  give  potas- 
sium bromide,  15  gr.  every  3  hours,  as  needed  to  give  rest  and  sleep.  This 
makes  the  patient  much  more  comfortable,  and,  in  addition,  the  bromides 
(particularly  potassium  bromide)  are  supposed  to  aid  somewhat  in  check- 
ing excessive  menstrual  flow. 

If  the  pain  is  severe,  the  bromides  will  probably  not  be  sufficient  to  relieve 
it,  and  then  opium  is  indicated.  Besides  checking  the^atient's  sufferings,  the 
opium  has  a  decided  effect  toward  temporarily  checking  the  uterine  bleed- 
ing. "When  opium  is  given,  it  should  be  in  such  form  that  the  patient  does  not 
know  what  she  is  taking.  A  very  good  formula  is  ergot  in  one  grain  and 
opium  one-half  grain,  given  in  a  pill  and  repeated  every  six  to  eight  hours 
as  needed  (see  Formulae). 

5.  Medicine  for  Special  Indications.  If  there  is  heart  trouble  with  failing 
compensation,  digitalis  or  other  heart  stimulant  is  indicated. 

If  there  is  a  troublesome  cough,  or  bladder  or  rectal  disturbance,  or  other 
affection,  give  medicine  for  the  same. 

6.  Vaginal  Tamponade.  Another  method  and  a  very  efficient  one  for  tem- 
porarily cheeking  a  serious  loss  of  blood  during  menstruation  is  to  tampon 
the  vagina  firmly,  the  same  as  for  hemorrhage  from  any  other  cause.  This 
temporarily  stops  the  loss  of  blood  from  the  relaxed  atonic  uterus  and  pre- 
serves that  much  for  the  anemic  patient,  Avho  can  ill  afford  to  lose  it.  This 
packing  may  be  removed  in  one  or  two  days,  and  another  applied. 

The  systematic  use  of  this  method  in  suitable  cases  was  brought  before  the 
profession  by  Dr.  E.  C.  Gelirung,  who,  from  an  extensive  experience  with  it, 
states  that  no  ill-effect  follows  this  arbitrary  checking  of  the  menstrual 
flow  after  a  proper  amount  of  blood  has  been  lost.  It  is  a  useful  temporary 
expedient  for  preserving  to  the  anemic  patient,  over  a  few  menstrual  periods, 
the  ])lood  which  she  can  ill  afford  to  lose  by  stopj-ting  the  flow  after  the  third 
or  fourth  day  of  mcpstrnation.  In  this  way  the  downward  course  of  the 
trouble  may  becheckoci  and  the  patient's  condition  held  stationary,  while 
other  measures  are  employed  to  overcome  the  cause  of  the  excessive  menstrua- 
tion. 

(B.)    Treatment  Between  Menstrual  Periods. 

Having  checked  the  flow  temporarily,  the  next  thing  is  to  prevent  the  re- 
currence of  the  excessive  menstruation.    The  indications  in  such  cases  are : 


DYSMENORRHOEA  8g7 

To  reduce  congestion  of  Ihc  ulci-iis  and  other  pelvic  slruetures. 

To  tone  up  the  uterus. 

To  put  the  patient's  blood  in  good  condition. 

To  correct  local  diseases. 

The  measures  for  accomplishing  these  objects  are  as  follows: 

1.  Laxatives.  There  should  be  one  or  two  good  bowel  movements  daily, 
and  at  the  menstrual  period  the  bowels  should  be  given  a  special  clearing 
out. 

2.  Uterine  Tonics.  Ergot  is  one  of  the  best  drugs  for  toning  up  an  atonic 
uterus.  It  produces  also  some  constriction  of  the  blood  vessels  and  thus  di- 
minishes the  amount  of  blood  in  the  organ.  This  has  a  marked  effect  in 
checking  excessive  loss  of  blood.  The  ergotin  and  nux  vomica  capsule  (see 
Formulae)  is  an  excellent  form  in  which  to  give  the  ergot.  This  may  be 
given  three  times  daily,  between  the  periods.  It  is  a  good  general  tonic.  At 
the  menstrual  period  it  is  well  to  increase  the  frequency  to  every  6  hours. 

Stypticin,  styptol  or  the  other  hemostatics  mentioned  under  "treatment 
during  the  flow"  may  be  administered  during  the  intermenstrual  period. 

3.  General  Tonic  Remedies.  Menorrhagia  is  not  a  disease.  It  is  only  a 
symptom,  and  the  physician  must  find  what  is  back  of  it  as  an  etiological 
factor. 

If  anemia  is  present,  the  cause  must  be  sought  and  the  patient  placed  on 
the  required  tonic  regimen  and  medication. 

If  there  is  heart  disease,  portal  obstruction  or  any  other  condition  that  in- 
terferes with  the  return  of  blood  from  the  pelvis,  it  must  receive  appropriate 
treatment. 

4.  Correction  of  Local  Disturbances.  Any  local  disease  present  should  be 
determined  and  treatment  instituted  accordingly.  This  is  a  very  important 
part  of  the  treatment  of  menorrhagia  and  tends  more  than  anything  else  to 
bring  about  a  permanent  cure.  The  pelvic  disorders  that  may  cause  menor- 
rhagia have  just  been  enumerated  and  the  various  methods  of  treatment  are 
given  in  the  appropriate  chapters. 

Often  the  correction  of  a  retro-displacement  and  the  retention  of  the  uterus 
in  proper  position,  by  pessary  or  otherwise,  will  effect  a  cure  of  menorrhagia. 

In  some  cases  of  hyperplasia  of  the  endometrium  from  simple  endometritis 
or  subinvolution  or  fibromyoma,  astringent  intra-uteriue  applications,  made 
once  or  twice  weekly  in  the  intermenstrual  period,  may  suffice  to  overcome 
the  excessive  menstrual  floAV.  In  other  cases  it  Avill  be  necessary  to  employ 
curetment.  Intra-uterine  treatment  (applications  or  curetment)  should  al- 
ways be  accompanied  by  such  assisting  measures  as  are  indicated. 

[Metrorrhagia  (bleeding  between  the  menses)  is  considered  on  page  904.] 

PAINFUL  MENSTRUATION  (DYSMENORRHOEA). 

Dysmenorrhoea  is  the  most  troublesome  of  the  menstrual  disturbances, 
causing  many  women  to  suffer  from  one  to  several  days  every  month.    In 


868  DISTURBANCES  OF  FUNCTION 

some  cases  the  suffering  is  so  severe  that  menstruation  constitutes  a  monthly- 
torture,  which,  aside  from  the  immediate  pain,  leaves  the  patient  worn  and 
weak  for  many  days  afterwards,  and  she  lives  in  constant  dread  of  the  next 
menstrual  period.  Even  in  the  milder  cases  the  constant  recurrence  of 
pain  and  physical  and  mental  depression  may  gradually  induce  a  serious  con- 
dition of  malnutrition  and  neurasthenia. 

Dysmenorrhoea  is  not  a  disease,  but  only  a  symptom.  It  is  caused  by  a 
great  variety  of  conditions  and  is  a  symptom  of  many  pelvic  diseases.  How- 
ever, no  one  organic  lesion  has  been  shown  to  be  the  essential  or  sufficient 
cause  of  menstrual  pain,  for  every  condition  so  considered  at  one  time  or 
another  has  been  found  to  exist  in  some  instances  without  accompanying 
menstrual  pain. 

It  is  apparent  that  in  practically  every  case,  dysmenorrhoea  is  due  to  a 
combination  of  abnormal  conditions,  either  local  or  general  or  both.  The 
work  of  the  physician  in  each  case  is  (a)  to  determine  the  abnormal  condi- 
tions present  in  that  particular  case,  (b)  to  form  an  estimate  of  the  rela- 
tive importance  of  each  in  the  causation  of  the  menstrual  distress  and  (c)  to 
treat  the  patient  accordingly. 

It  has  been  customary  to  group  the  cases  of  dysmenorrhoea  into  four 
classes  as  follows,  each  class  supposedly  representing  distinct  etiological  fac- 
tors: 

Neuralgic  or  Ovarian  Dysmenorrhoea. 

Congestive  or  Inflammatory  Dysmenorrhoea. 

Obstructive  or  Mechanical  Dysmenorrhoea. 

Membraneous  Dysmenorrhoea. 

Neuralgic  dysmenorrhoea  is  simply  neuralgia  of  the  ovarian,  uterine  and 
other  pelvic  nerves,  coming  on  at  the  menstrual  period  because  of  the  in- 
creased pelvic  congestion  and  the  greater  impressionability  of  the  nervous 
system  generally  at  that  time. 

The  pain  is  neuralgic  in  character — i.  e.,  sharp  and  variable.  It  radiates 
from  the  ovarian  region  of  one  or  both  sides  to  the  uterus  and  to  the  iliac, 
abdominal,  lumbar  and  sacral  regions.  Not  infrequently  it  extends  down  the 
tliighs.  In  a  large  proportion  of  the  cases  there  is  a  severe  attack  of  head- 
ache at  some  part  of  the  menstrual  epoch  and  occasionally  a  distinct  neural- 
gia in  some  other  part  of  the  body.  The  pain  appears  to  be  independent  of 
the  character  of  the  menstrual  flow.  It  may  l)e  most  intense  a  day  or  two 
before  the  flow  or  it  inay  come  on  after  the  flow,  or  it  may  come  and  go 
during  IIm^  whohvtiine.  Tluis  it  is  erratic  and  is  likely  to  vary  much  in  the 
difi'crcnt  mcnstrnal  periods  witliout  apparent  cause. 

This  form  of  dysmenorrlioea  0(;curs  usually  in  women  of  a  neuralgic  or 
rheumatic  diathesis.  Neuralgic  or  rheumatic  pains  are  often  felt  in  the  in- 
termenstrual periods,  either  in  the  pelvis  or  elsewhere.  Hyperesthesia'  over 
the  abdominal  surface  and  pain  are  frequently  noticeable,  and  this  is  much 
increased  at  the  menstrual  time. 


DYSMENORRHEA  ggQ 

This  form  of  dysmenorrlioea  is  lia])lo  to  he  associated  with  anemia,  in- 
digestion, neurasthenia,  liysteria  and  allied  disturl)ances.  Patients  with 
rheumatism  and  gout  are  also  particularly  prone  to  menstrual  pain  without 
apparent  causative  lesion  in  the  pelvis.  In  the  cases  of  so-called  "neuralgic" 
dysmenorrhoea,  ovarian  pain  usually  plays  a  prominent  part — so  prominent 
that  this  is  sometimes. referred  to  as  "ovarian  dysmenorrhoea." 

Congestive  or  inflammatory  dysmenorrhoea  is  due  to  congestion  within 
the  pelvis,  particularly  congestion  of  the  uterine  mucosa.  This  congestion 
may  be  due  to  some  inflammation  in  the  uterus  or  around  it,  or  it  may  be  due 
to  some  non-inflammatory  condition,  such  as  uterine  displacement,  or  a  tumor 
of  the  uterus  or  vicinity,  or  a  functional  pelvic  congestion  (page  864). 

The  pain  is  that  of  inflammation,  and  is  felt  as  a  soreness  or  throbbing 
pressure  in  the  pelvis  or  back.  It  may  radiate  into  the  iliac  regions,  or  up  the 
spine  or  down  the  thighs.  If  the  inflammation  is  principally  in  one  side  of 
the  pelvis,  the  pain  is  most  severe  there. 

The  pain  is  usually  most  severe  the  first  day  or  two  of  the  flow,  but  may 
last  all  the  time.  The  pain  may  begin  a  day  or  two  before  the  flow,  and  this 
is  especially  liable  to  occur  in  those  cases  of  inflammatory  trouble  involving 
the  ovary.  There  is  also  much  general  soreness  through  the  pelvis,  which 
is  increased  by  walking  or  standing. 

The  diagnostic  sign  of  this  variety  of  dysmenorrhoea  is  the  character  and 
constancy  of  the  pain  and  the  fact  that  there  is  trouble  between  the  menses — 
evidence  of  inflammation  or  displacement,  or  tumor  or  something  that  keeps 
up  chronic  pelvic  congestion.  The  various  causes  of  pelvic  congestion  are 
mentioned  in  detail  under  menorrhagia  (page  863). 

Obstructive  or  mechanical  dysmenorrhoea  is,  as  its  name  implies,  depend- 
ent on  the  obstruction  to  the  outflow  of  the  menstrual  blood.  The  obstruc- 
tion may  be  due  to  circular  stenosis  of  the  canal  from  imperfect  development, 
or  from  cicatricial  narrowing  or  from  spasmodic  constriction  of  the  circu- 
lar muscle  fibers,  or  from  swelling  of  the  uterine  mucosa.  It  may  be  due  also 
to  a  sharp  bend  in  the  canal  due  to  flexion  of  the  uterus — usually  an  anteflex- 
ion, occasionally  a  retroflexion.  The  obstruction  is  usually  found  about  the 
internal  os,  though  in  very  exceptional  cases  it  may  be  at  some  other  point 
along  the  canal  or  at  the  external  os.  The  canal  may  be  narrowed  by  a  tumor 
situated  in  the  cervix  or  outside  the  uterus.  A  small  polypus  within  the 
uterus  may  drop  into  or  against  the  internal  os  and  block  it.  Again,  the  men- 
strual blood  may  contain  clots,  which  are  expelled  with  difficulty  even  when 
the  canal  is  of  normal  size. 

The  characteristic  of  mechanical  dysmenorrhoea  is  that  the  pain  is  par- 
oxysmal in  character,  apparently  corresponding  to  painful  uterine  contrac- 
tions brought  about  by  the  effort  of  the  uterus  to  force  the  blood  past  the 
obstruction.  The  pains  are  periodical — very  severe  at  times,  with  intervals 
of  rest  between— somewhat  on  the  order  of  the  pains  of  a  miscarriage.  When 
the  menstrual  flow  is  freely  established,  the  severe  pain  usually  disappears. 

Dysmenorrhoea  due  entirely  to  mechanical  causes,  or  obstruction,  is  rare. 


870  DISTURBANCES  OF  FUNCTION 

There  are  usuallv  complicating  conditions  that  are  as  important  as,  if  not  more 
important  than,  the  obstrnetion.  The  drsmenorrhoea  of  young  women,  so 
freqnentlv  associated  with  anteflexion,  was  for  a  long  time  supposed  to  be 
due  to  obstruction  in  the  canal.  But  it  is  now  known  that  the  obstruction 
is  only  one  of  the  factors,  and  in  most  cases  one  of  only  secondary  im- 
portance, as  explained  later  ("page  871). 

Membraneous  dysmenorrhoea  is  the  term  applied  to  that  form  of  painful 
menstruation  accompanied  by  the  expulsion  of  membrane  from  the  uterus. 
The  membrane  is  usually  passed  in  small  pieces,  though  occasionally  it  is 
thrown  oif  as  a  complete  cast  of  the  interior  of  the  uterus.  It  consists  of  the 
superficial  layers  of  the  uterine  mucous  membrane,  and  is  thrown  off  as  the 
result  of  nutritive  changes  which  are  not  yet  understood. 

The  pains  come  with  the  flow  and  are  paroxysmal — of  the  same  character 
as  the  pains  of  mechanical  dysmenorrhoea,  but  very  severe,  resembling  labor 
pains.  After  these  have  continued  for  several  hours  or  a  day  or  two,  pieces  of 
the  membrane  are  expelled.  There  is  then  relief  unless  other  pieces  pass. 
The  membrane,  mixed  with  the  menstrual  flow,  is  the  diagnostic  sign  of  this 
form  of  dysmenorrhoea.  Care  must  be  exercised  not  to  confound  it  with  mis- 
carriage. It  usually  recurs  every  month  or  so  and  may  last  for  years.  The 
cause  is  not  definitely  known. 

In  regard  to  the  above  classification,  with  the  exception  of  the  cases  of 
membraneous  dysmenorrhoea,  it  does  not  make  a  very  satisfactory  grouping 
of  the  eases.  In  a  few  patients  the  dysmenorrhoea  apparently  belongs  en- 
tirely to  one  of  the  forms  mentioned — i.  e.,  neuralgic  or  inflammatory  or 
obstructive.  In  most  cases,  however,  there  is  such  a  mixture  of  neuralgic, 
congestive  and  obstructive  features  that  it  is  impossible  to  assign  the  case  ex- 
clusively to  any  one  of  these  classes.  For  the  purposes  of  diagnosis  and 
treatment,  it  is  convenient  to  divide  the  cases  of  dysmenorrhoea  into  two 
groups — the  fir.st  group  including  the  cases  of  dysmenorrhoea  in  the  virgin 
and  the  second  group  including  the  cases  of  dysmenorrhea  in  the  married 
woman. 

(A.)    DYSMENORRHOEA  IN  THE  VIRGIN. 

The  patient,  a  girl  or  unmarried  woman,  comes  complaining  of  pain  at  the 
menstrual  periods.  The  pain  may  be  so  severe  that  the  patient  is  obliged 
to  go  to  bed  for  one  or  two  or  three  days  at  each  menstrual  period,  or  it  may 
be  less  severe,  so  that  she  is  able  to  be  up  and  about,  but  is  miserable.  Some- 
times the  pain  is  very  severe,  but  going  to  bed  gives  no  relief.  The  pain  may 
have  been  marked  from  the  first  menstruation  or  it  may  have  been  slight 
at  first,  with  gradual  increase  since.  There  is  usually  a  decided  difference  in 
the  pain  in  the  different  menstrual  periods,  being  much  more  troublesome  at 
some  periods  than  at  others.  In  many  cases  the  pain  begins  a  day  or  two 
before  the  flow.  It  is  usually  much  relieved  within  2-i  hours  after  the  flow 
is  well  established. 


DYSMENORRHOEA  IN  THE  VIRGIN  87]^ 

Along  with  the  menstrual  pain  there  may  be  loss  of  appetite,  nausea, 
lassitude  and  neuralgias.  There  is  nearly  always  decided  weakness  during 
the  flow  and  for  one  to  several  days  thereafter.  ^Menstruation  may  be  other- 
wise normal,  or  there  may  be  scanty  menstruation  or  exce.ssive  menstruation. 
In  many  cases  the  patient  has  no  particular  disturbance  during  the  inter- 
menstrual period. 

Causes  of  Dysmenorrhea  in  the  Virgin. 

The  causes  are  varied,  but  there  is  one  group  of  conditions  that  overtops 
all  others  in  the  frequency  of  occurrence.    I  shall  consider  it  first. 

1.  Neurotrophic  Dysmenorrhoea.  In  the  majority  of  cases  of  dysmenor- 
rhoea  in  the  virgin  there  is  a  combination  of  conditions,  comprising  anteflex- 
ion of  the  cervix,  some  stenosis  of  the  cervical  canal  and  marked  hyperes- 
thesia of  the  uterine  tissues,  especially  in  the  neighborhood  of  the  internal 
OS.  This  condition  is  a  very  important  one  on  account  of  the  frequency  of  its 
occurrence  and  the  suffering  it  causes  and  the  stubbornness  with  which  it 
resists  treatment  in  many  cases. 

What  is  the  Cause  of  the  Pain  in  These  Cases? 

It  was  for  a  long  time  supposed  to  be  due  to  the  narrowing  of  the  canal  at 
the  internal  os  by  the  anteflexion  present,  with  the  consequent  obstruction  to 
the  outflow  of  menstrual  blood.  That  the  obstruction  does  play  some  part  is 
shown  by  the  fact  that  when  the  obstruction  is  removed  the  pain  is  usually 
considerably  diminished.  But  simple  removal  of  the  obstruction  (dilatation  of 
cer^dcal  canal)  does  not  always  relieve  the  patient  entirely,  and  in  some 
cases  the  relief  from  this  measure  is  slight  or  wanting,  showing  conclusively 
that  the  obstruction  is  not  the  only  factor  in  the  case.  Again,  it  is  a  matter 
of  common  observation  that  some  patients,  with  as  much  or  more  anteflexion 
and  obstruction  as  are  found  in  these  cases,  have  no  dysmenorrhoea.  In  37 
cases  of  decided  anteflexion,  reported  by  A.  M.  Judd,  nine  were  "^vithout 
menstrual  pain,  19  had  menstrual  pain  beginning  before  the  flow  and  nine 
had  only  premenstrual  pain.  In  26  cases  of  anteflexion  in  the  unmarried, 
reported  by  C.  E.  Hyde,  five  had  no  menstrual  pain,  20  had  menstrual  pain 
beginning  before  the  flow  and  one  had  pain  only  after  the  flow.  So  the  essen- 
tial disturbance  must  be  sought  further.  Endometritis  has  been  put  forward 
as  the  cause  of  the  pain — at  least  of  that  portion  of  it  which  is  not  relieved  by 
the  removal  of  the  obstruction.  But  this  hypothesis  also  fails.  In  not  a  few 
cases  of  dysmenorrhoea  persisting  after  dilatation  the  mucosa,  removed  by 
curetment,  has  been  found  to  be  practically  normal.  On  the  other  hand,  many 
patients  with  decided  endometritis  have  no  particular  menstrual  pain. 

There  is  one  pathological  condition  that  seems  to  be  fairly  constant  in  the 
class  of  cases  under  consideration,  and  that  is  h^^)eresthesia  or  marked  irrita- 
bility of  the  nerves  of  the  uterine  mucosa  and  muscles,  especially  in  the 
neighborhood  of  the  internal  os.  This  is  noticeable  on  sounding  the  uterus 
and  especially  on  dilating  the  internal  os  without  anesthesia.    It  is  indicated 


872  DISTURBANCES  OF  FUNCTION 

also  by  the  painful  muscular  contraction  or  uterine  "cramps"  occurring  witH- 
out  apparent  cause.  The  theory  that  the  essential  or  underlying  condition 
in  these  cases  is  hyperesthesia  of  the  mucosa  and  muscle  due  to  a  nutritive 
disturbance,  affecting  the  nerves  and  other  tissues,  seems  to  be  the  most  tenable 
one.  It  explains  better  than  any  other  hypothesis  yet  advanced  the  various 
phenomena  observed.  It  shows  why  the  symptoms  may  persist  to  a  greater  or 
less  extent  after  removal  of  the  obstruction  at  the  internal  os  and  after 
removal  of  the  hyperplastic  mucosa.  It  shows  why  the  symptoms  occur  in 
patients  with  no  obstruction  and  with  no  decided  structural  change  in  the 
mucosa.  It  shows  why  measures  directed  toward  improving  nutrition  and 
allaying  nerve  irritability  will  sometimes  produce -decided  improvement  with- 
out any  local  treatment.  In  short,  it  explains  wh^it  has  already  been  worked 
out  clinically — that  the  narrowing  of  the  canal  and  thickening  of  the  endome- 
trium are  simply  complications  that  may  or  may  not  be  present.  When  they 
are  present  they  aggravate  the  trouble  and  require  treatment.  But  unless 
the  nutritive  disturbance  of  the  uterine  muscle  and  mucosa  is  also  improved 
sufficiently  to  restore  the  nerves  to  fairly  normal  condition,  the  pain  will  con- 
tinue to  a  considerable  extent. 

The  marked  effect  of  pregnancy  and  parturition  is  these  cases  points 
strongly  to  its  being  largely  a  nutritive  disturbance.  Pregnancy  has  a  most 
profound  influence  upon  the  nutrition  of  the  uterus.  To  be  sure,  the  parturi- 
tion effectively  overcomes  the  stenosis,  but  this  does  not  account  for  the  uni- 
form and  marked  benefit,  for  we  have  already  found  that  in  many  cases  the 
stenosis  is  not  an  important  factor.  The  beneficial  effect  of  curettage  in 
these  cases  is  likev.dse  due,  to  a  large  extent,  to  its  marked  stimulation  of 
the  nutrition  of  the  uterus. 

Another  point  in  favor  of  the  supposition  that  this  trouble  is  essentially 
a  nutritive  disturbance  affecting  the  whole  uterus  (both  muscular  tissue  and 
mucosa)  is  the  fact  that  it  is  very  frequently  accompanied  by  evidences  of 
imperfect  development.  Such  cases  are  referred  to  as  cases  of  "infantile 
uterus."  The  evidences  of  imperfect  development  are  late  beginning  of  the 
menses,  irregular  menstruation  and  decided  anteflexion  of  the  cervix  (failure 
of  the  cervix  to  take  its  proper  direction  across  the  vaginal  canal).  In  fact, 
the  association  of  imperfect  development  Avith  tliis  form  of  dysmenorrhoea 
is  so  common  that  some  writers  attribute  the  dysmenorrhoea  to  the  imper- 
fect development.  It  seems  to  me,  however,  that  a  better  view  of  the  matter 
is  that  the  imperfect  development  and  the  dysmenorrhoea  are  both  due  to  the 
same  cau::e — viz.,  poor  nutrition. 

I  think  we  may  go  a  step  further  and  say  that  these  two  conditions— im- 
perfect development  and  neurotrophic  dysmenorrhoea— are  due  to  poor 
nutrition  largely  at  a  certain  period  of  life— namely,  at  the  period  of  puberty. 
The  victims  who  suffer  most  are  usually  women  who  during  puberty  were 
poorly  nourished  from  a  physical  and  developmental  standpoint  and  were 
subjected  to  influences  that  wouhl  rotnrd  uterine  development  (see  page 
854).    In  many  cases  this  poor  nutrition  persists,  and  is  only  too  apparent 


DYSMENORRHOEA  IN  THE  VIRGIN  873 

when  the  patient  comes  to  the  physician  to  secure  relief  from  the  dysmenor 
rhoea.  In  other  cases  the  patient,  having  been  for  some  time  out  of  school 
and  taking  more  fresh  air  and  sunshine  and  exercise,  has  acquired  good 
blood  and  a  good  color.  But  that  has  not  been  sufficient  to  correct  the  evil 
effects  of  a  pernicious  regimen  during  puberty — a  regimen  which  promoted 
mental  activity  at  the  .expense  of  physical  development. 

2.  Membraneous  Dysmenorrhoea.  This  form  of  dysmenorrhoea,  or  rather 
the  meaning  of  the  term,  has  been  explained  (see  page  870).  The  cause  and 
exact  pathology  are  still  in  doubt.  It  is  sometimes  designated  as  "exfoliative 
endometritis,"  though  careful  examination  of  the  exfoliated  membrane  has 
shown  that  in  some  cases  no  endometritis  is  present. 

Membraneous  dysmenorrhoea  is  a  comparatively  rare  affection.  It  usually 
appears  early  in  sexual  life,  though  some  cases  have  been  reported  in  which 
the  disease  first  appeared  in  middle  life.  It  usually  extends  over  several 
years.  At  certain  menstrual  periods  the  endometrium  is  cast  off  and  appears 
in  the  menstrual  discharge  as  shreds.  Occasionally  the  mucosa  is  cast  off  as 
one  piece,  forming  a  cast  of  the  uterine  cavity.  The  detachment  and  ex- 
pulsion of  a  membrane  with  the  menstrual  flow  (decidua  menstrualis)  may  take 
place  when  the  endometrium  is  practically  normal  in  structure  or  when  it  is 
the  seat  of  one  or  more  of  the  several  inflammatory  and  nutritive  changes 
already  described.  The  expelled  pieces  will,  of  course,  exhibit  whatever  struc- 
tural change  is  presnt  in  the  endometrium ;  consequently  in  a  series  of  cases 
of  membraneous  dysmenorrhoea,  examination  of  the  membrane  may  show  many 
dift'erent  inflammatory  and  nutritive  changes,  none  of  which  are  peculiar  nor 
distinctive  of  membraneous  dysmenorrhoea,  but  due  to  independent  patho- 
logical conditions  in  the  endometrium. 

Membraneous  dysmenorrhoea  is  undoubtedly  due  to  a  marked  nutritive 
change,  but  just  what  lies  back  of  this  nutritive  change  has  not  been  certainly 
determined.  F.  F.  Lawrence,  in  reporting  a  number  of  cases,  advanced  the 
idea  that  the  condition  is  usually  due  to  pelvic  inflammation  following  an 
attack  of  one  of  the  exanthemata  near  puberty.  He  reported  42  cases  of 
membraneous  dysmenorrhoea  in  which  there  was  present  tubal  or  ovarian 
disease  requiring  operation.  In  19  cases  the  disease  was  unilateral  and  in 
the  remaining  bilateral.  In  33  of  the  42  cases  the  trouble  appeared,  from  the 
history,  to  have  started  from  an  attack  of  scarlatina,  measles,  mumps,  rheu- 
matism or  small-pox.  In  nearly  all  (the  report  is  not  definite)  there  was  no 
further  membraneous  dymenorrhoea  after  the  removal  of  the  pelvic  disease. 
He  concludes  that  membraneous  dysmenorrhoea  is  due  to  trophic  changes  in 
the  endometrium  secondary  to  adnexal  disease,  and  that  this  adnexal  disease 
is  usually  a  sequel  of  one  of  the  exanthemata  occurring  near  puberty.  He 
concludes  also  that  the  adnexal  disease  is  usually  unilateral  at  first  and  may  be 
prevented  from  extending  to  the  other  side  by  prompt  attention.  As  a  result 
of  these  conclusions,  he  holds  (a)  that  tubal  and  ovarian  complications  occur- 
ring with  the  exanthemata  near  puberty  should  be  watched  for  and  treated, 
(b)  that  in  every  case  of  membraneous  dysmenorrhoea  a  careful  history  should 


874  DISTURBANCES  OF  FUNCTION 

be  gotten  ^vith  that  point  in  \ievr,  (c)  that  when  unilateral  adnesnal  disease 
is  found,  prompt  operation  should  be  carried  out  to  prevent  the  trouble  be- 
coming bilateral,  and  (d)  that  the  facts  in  the  case  "would  seem  to  warrant 
removal  of  the  tubes  and  ovaries  on  one  or  both  sides  when  shreds  or  casts 
are  a  part  of  painful  menstruation. 

The  facts  brought  out  above  are  certainly  interesting,  and  study  along 
this  line  may  help  to  clear  up  part  of  this  subject.  "With  the  last  conclusion, 
however,  I  must  differ  most  decidedly.  Eemoval  of  the  adnexa  on  one 
or  both  sides  should,  as  a  rule,  be  made  only  for  a  distinct  adnexal  lesion  and 
not  simply  for  painful  menstruation,  whether  accompanied  by  shreds  or  not 
(page  888).  The  fallacy  of  operating  simply  for  the  dysmenorrhoea  is  shown 
by  the  fact  that  the  dysmenorrhoea  may  be  as  severe  after  operation  as  be- 
fore. This  fact  was  brought  out  in  the  discussion  of  the  above  paper  by  L.  H. 
Dimning,  who  stated  that  "one  of  the  most  severe  cases  of  membraneous 
dysmenorrhoea  he  ever  saw  occurred  in  a  woman  after  he  had  removed  bilat- 
eral pus  tubes  and  both  ovaries.  She  menstruated  for  two  years  afterward 
and  had  membraneous  dysmenorrhoea."  In  a  pre^aous  paper  Dr.  Dunning 
had  reported  a  case  of  membraneous  dysmenorrhoea  which  persisted  after 
abdominal  section  and  treatment  of  the  adnexal  disease,  and  finally  yielded 
to  intra-uterine  applications  of  electricity. 

Concerning  diagnosis  of  membraneous  dysmenorrhoea  in  the  virgin,  the 
passage  of  shreds  of  membrane  with  the  menstrual  flow  establishes  the 
diagnosis.  There  is  no  other  affection  of  \-irgins  presenting  such  symptoms. 
It  is  well,  however,  to  have  some  of  the  membrane  saved  for  inspection  and 
microscopic  examination,  for  the  patient  may  be  deceived  by  blood  clots  or 
shreds  of  bloody  mucus.  It  must  be  kept  in  mind,  also,  that  in  certain  cases 
the  supposed  virgin  maj'  not  be  a  virgin,  and  that,  consequently,  the  sup- 
posed "decidua  menstruaUs  ^ '  may  be  a  decidua  of  a  different  character  (page 
858). 

3.  Atrophy  of  Uterus.  In  certain  cases  in  virgins  past  30  years  of  age 
and  also  in  sterile  married  women  there  seems  to  be  some  atrophy  of  the 
uterus,  which  has  failed  to  receive  the  stimulus  of  pregnancy.  The  patient 
had  no  particular  pain  in  her  earlier  years,  but  gradually  menstrual  suffering 
has  appeared,  and  examination  shows  no  lesion,  except  a  rather  small  at- 
rophic) cervix,  with  more  or  less  stenosis.  This  is  really  a  form  of  neurotrophic 
dysmenorrhoea,  but  is  due  to  trophic  disturbance  in  later  years  instead  of 
during  the  developmental  period.  This  is  one  of  the  classes  in  which  the  stem 
pessary  is  sometimes  advisable  (page  882). 

4.  Backward  Displacement  of  the  Uterus.  Painful  menstruation  is  one  of 
the  symptoms  freqm-ntly  produced  by  marked  retrodisplacement  of  the 
uterus.  Kelly  found  that  of  229  consecutive  cases  of  dysmenorrhoea  admitted 
to  Johns  Hopkins  Hospital,  41  per  cent,  were  associated  with  retrodisplace- 
ment of  the  uterus,  37  per  cent,  with  pelvic  inflammatory  disease,  and  11 
per  cent,  with  fibromyoraata.  The  proportion  of  cases  of  retrodisplacement 
is,  of  course,  much  larger  in  patients  who  have  borne  children  than  in  virgins. 


DYSMENORRHOEA  IN  THE   VIRGIN  g75 

In  184  cases  of  retrodisplacement  of  the  uterus,  reported  by  A.  M.  Judd,  108 
suffered  with  menstrual  pain,  either  during  the  flow  or  immediately  before 
it.  A  slight  retrodisplacement  of  the  uterus,  less  than  the  second  degree, 
does  not  give  rise  to  particular  disturbance  and  should  not  be  accepted  as 
the  cause  of  dysmenorrhoea. 

5.  Fibromyomata  of  the  Uterus.  Painful  menstruation  is  a  frequent  symp- 
tom in  uterine  myoniata,  particularly  when  the  nodules  are  interstitial  or 
submucous. 

6.  Chronic  Pelvic  Inflammation  (salpingitis,  oophoritis,  cystic  ovary).  Sal- 
pingitis is  comparatively  rare  in  the  virgin,  for  the  various  causes  of  pelvic 
inflammation  in  the  married  woman  are  not  present.  Chronic  oophoritis 
from  local  circulatory  and  nutritive  disturbance  is  more  frequent  and  may 
give  rise  to  some  dysmenorrhoea. 

7.  Pelvic  Tuberculosis.  This  is  not  so  rare  as  was  formerly  supposed,  and 
should  be  thought  of  whenever  there  are  evidences  of  chronic  pelvic  inflam- 
mation in  a  virgin. 

8.  Ovarian  or  Broad  Ligament  Tumors.  These  may  arise  in  the  virgin  and 
give  rise  to  the  usual  symptoms  and  signs,  which  are  detailed  in  the  appro- 
priate chapter. 

9.  Inflammation  of  Adjacent  Organs — bladder,  rectum,  appendix.  Any  adja- 
cent inflammatory  trouble  is  likely  to  be  considerably  aggravated  by  the 
menstrual  congestion.  Occasionally  the  trouble  is  so  slight  as  to  be  hardly 
noticeable  except  during  the  menstrual  exacerbation.  In  such  a  case  it  may 
at  first  be  considered  one  of  the  usual  varieties  of  dysmenorrhoea,  but  careful 
watching  will  show  symptoms  pointing  to  the  organ  involved,  and  evidence 
of  such  disturbance  may  be  found  in  the  intermenstrual  period.  Chronic  ap- 
pendicitis not  infrequently  presents  decided  menstrual  exacerbations.  And 
in  some  eases  the  intermenstrual  symptoms  are  so  slight  or  indefinite  that 
the  true  nature  of  the  affection  is  not  suspected  until  abdominal  examination 
shows  tenderness  at  McBurney's  point  and  other  evidences  of  chronic  appen- 
dicitis. 

10.  Functional  Pelvic  Congestion.  Chronic  functional  congestion  of  the 
pelvis,  due  to  constant  standing,  long  walking  or  other  causes  (page  864), 
may  cause  very  troublesome  dysmenorrhoea. 

11.  Reflex  Dysmenorrhoea.  There  are  occasional  cases  of  dysmenorrhoea 
apparently  due  to  reflex  disturbance  from  a  distant  part  of  the  body.  One  of 
the  most  striking  of  such  reflex  connections  is  that  from  within  the  nose. 
In  certain  cases,  dysmenorrhoea  has  apparently  been  due  to  some  pathological 
intranasal  condition  and  has  been  relieved  by  treatment  of  the  same.  These 
are  sometimes  referred  to  as  cases  of  "nasal  dysmenorrhoea."  In  certain 
other  cases,  menstrual  pain  has  been  relieved  by  cocainization  of  particular 
areas  of  the  normal  nasal  mucosa.  This  fact  was  first  brought  to  the  attention 
of  the  profession  by  Fliess,  a  German  rhinologist,  who  in  1897  presented  to 
the  Berlin  Obstetrical  Society  a  paper  detailing  his  experiments  in  that  direc- 
tion.   He  found   that  in  some  cases  of    dysmenorrhoea   the  pain  disappeared 


876  DISTURBANCES  OF  FUNCTION 

within  a  few  minutes  after  the  application  of  a  20  per  cent,  cocaine  solution 
to  certain  areas  in  the  nose.  These  areas  were  the  anterior  end  of  the  inferior 
turbinated  bone  of  each  side,  and  a  spot  just  opposite  this  on  the  septum,  some- 
times referred  to  as  the  tuberculum  of  the  septum. 

Fliess  in  his  experiments  divided  the  cases  of  dysmenorrhoea  which  he 
encountered  into  two  classes — first,  those  in  which  the  pain  ceased  as  soon 
as  the  menstrual  flow  began,  and,  second,  those  in  which  the  pain  continued 
along  Avith  the  flow.  In  the  first  class  he  noticed  no  particular  effect  from 
the  intranasal  cocaine  application.  In  the  second  class,  those  in  which  the 
pain  continued  during  the  flow,  the  effect  of  the  application  of  cocaine  to 
the  areas  mentioned  was  striking.  Usually  within  five  to  seven  minutes  after 
the  application  the  pain  ceased,  and  did  not  reappear  during  that  menstrua- 
tion. In  some  cases  there  was  a  pathological  condition  involving  the  areas 
mentioned,  but  the  same  result  was  obtained  in  many  cases  in  which  no  dis- 
ease was  apparent.  To  eliminate  "suggestion"  as  a  factor  in  the  case,  the 
application  of  cocaine  was  made  to  other  intranasal  areas,  instead  of  to  those 
mentioned,  and  there  was  no  result.  Again,  the  designated  areas,  which  are 
sometimes  referred  to  as  the  "genital  spots,"  were  touched  with  an  inert 
solution  and  there  was  no  result.  Again,  in  those  cases  in  which  temporary 
relief  followed  the  application  of  cocaine  to  the  intranasal  genital  spots, 
cauterization  of  those  areas  produced  a  cure,  either  permanent  or  lasting 
several  months. 

Good  results  have  since  been  obtained  by  other  reliable  observers  in  various 
parts  of  the  world  and  this  measure  has  been  established  as  useful  in  the 
treatment  of  certain  cases  of  dysmenorrhoea.  It  has  also  served  to  call  atten- 
tion to  the  fact  that  certain  pathological  conditions  in  the  nose  may  give 
rise  to  troublesome  dysmenorrhoea,  and  hence  in  a  case  of  dysmenorrhoea  that 
persists  without  apparent  cause  a  careful  rhinological  examination  should  bei 
made  to  exclude  nasal  trouble  or  to  discover  and  remove  it. 

12.  Neurasthenia.  The  neurasthenic  individual  is  prone  to  pains  in  the 
pelvis,  as  in  other  parts  of  the  body,  and,  of  course,  they  are  likely  to  be 
most  severe  at  the  menstrual  time.  These  pelvic  pains  occur  without  any  ap- 
parent local  cause.  The  cases  usually  present  the  characteristic  of  "neuralgic 
dysmenorrhoea."  Such  patients  are  often  subjected  to  ineffectual  treatment 
for  many  months — until  the  practitioner  grasps  the  fact  that  he  is  dealing, 
not  with  a  local  condition,  but  with  a  widespread  affection  of  the  nervous 
system. 

13.  Hysteria.  In  patients  with  hysteria  the  disturbances  may  be  much 
increased  at  the  menstrual  time.  In  some  cases  the  hysterical  manifestations 
between  the  periods  are  so  slight  that  hysteria  is  not  suspected  until  a  careful 
examination  is  made. 

Treatment  of  Dysmenorrhoea  in  the  Virgin. 

In  a  case  of  dysmenorrhoea  in  a  virgin  a  local  examination  is  not  called 
for  at  first,  unless  the  patient  has  taken  a  course  of  treatment  without  decided 


DYSMENORRHOEA   iN   THE  VIRGIN  877 

benefit  or  there  are  symptoms  indicating  some  decided  local  lesion.  If  there 
are  no  symptoms  between  the  menses,  indicating  some  gross  lesion,  it  is  to 
be  assumed  that  the  menstrual  pain  is  due  to  that  most  frequent  cause — 
defective  nutrition  with  uterine  hyperesthesia,  anteflexion  of  cervix  and 
more  or  less  stenosis  of  the  cervical  canal.  This  condition  may,  for 
convenience,  be  designated  as  "neurotrophic"  dysmenorrhoea  (page  871). 
The  management  of  tlie  cases  may  be  conveniently  divided  into  two  parts — 
treatment  during  the  menstrual  flow  and  treatment  between  the  periods. 

Treatment  During  the  Flow. 

Suppose  you  are  called  to  see  the  patient  while  she  is  menstruating  and 
in  much  pain.     The  first  thing  to  do  is  to  relieve  her  immediate  suffering. 

1.  General  Measures.  Put  the  patient  to  bed  and  have  hot  stupes  applied 
to  the  lower  abdomen,  and  the  bowels  freely  opened  by  an  enema  or  a  purga- 
tive or  by  both.  In  some  cases  you  will  find  that  the  patient  has  already  car- 
ried out  this  part  of  the  program  and  has  also  taken  hot  drinks  of  various 
kinds,  having  found  by  experience  that  these  measures  diminish  the  pain. 

2.  Sedatives  Internally.  For  further  relief,  if  the  pain  is  troublesome  in 
spite  of  the  above  measures,  give  some  sedative.  The  time-honored  viburnum 
prunifolium  will  often  give  considerable  relief.  It  may  be  given  either  as 
the  plain  fluid  extract  or  in  the  form  of  one  of  the  less  nauseating  and  more 
effective  preparations  supplied  by  reliable  manufacturing  drug  houses — for 
example,  Liquor  Sedans  (P.  D.  &  Co.),  which  contains  4  gr.  of  viburnum,  8  gr. 
of  hydrastis,  4  gr.  of  Jamaica  dogwood  and  5  gr.  of  cascara  to  each  teaspoon- 
ful.  If  the  pain  is  severe,  this  is  not  sufficient  for  immediate  relief.  For  the 
severe  pain  I  usually  prescribe  phenacetin  and  codein  (Formulae).  There  are 
a  number  of  other  preparations  that  are  sometimes  used  with  benefit,  among 
them  camphor,  fluid  extract  of  cimicifuga  and  aromatic  spirits  of  ammonia. 
In  those  cases  in  which  nervousness  is  a  prominent  feature  I  give  sodium 
bromide  in  10  gr.  to  20  gr.  doses  every  three  hours  until  the  general  nervous 
irritability  subsides.  The  ''dysmenorrhoea  mixture"  containing  postassium 
broniid,  guar  ana  and  celery  (Formulae)  is  highly  spoken  of. 

Morphine  is  rarely  necessary.  "When  the  pain  cannot  be  otherwise  relieved, 
morphine  may  be  given  for  temporary  relief,  but  it  should  be  given  in  such  a 
way  that  the  patient  does  not  know  what  she  is  taking.  The  above  measures 
usually  give  the  patient  relief,  but  she  should  stay  in  bed  as  long  as  there  is 
any  tendency  of  the  pain  to  be  severe. 

3.  Intranasal  Applications.  This  may  be  tried  in  those  cases  in  which  the 
pain  persists  after  the  flow  is  well  established.  Schiff  found  this  treatment 
effective  in  35  out  of  41  cases  in  which  it  was  tried.  Ephraim  reported  18 
successes  in  24  cases,  and  Linder  10  successes  in  16  cases.  It  has  proved  suc- 
cessful in  some  cases  that  persisted  in  spite  of  dilatation  and  curetment  and 
various  kinds  of  internal  medication.  On  the  other  hand,  it  has  failed  com- 
pletely in  cases  that  apparently  should  have  been  relieved  by  it.    It  is  uncer- 


g7g  DISTURBANCES  OF  FUNCTION 

tain,  but  is  worthy  of  trial  in  selected  eases.     When  using  this  treatment  re- 
member the  following  points: 

a.  The  application  is  m.ade  in  each  nostril,  to  the  region  including  the  an- 
terior end  of  the  inferior  turbinated  bone  and  the  adjacent  portion  of  the 
septum. 

b.  The  strength  of  the  cocaine  solution  usually  used  is  20  per  cent.,  though 
possibly  a  Aveaker  solution  (e.  g.,  10  per  cent.)  would  do. 

c.  The  application  should  be  made  by  the  physician  only,  and  the  patient 
should  not,  as  a  rule,  know  what  is  being  applied.  The  solution  should  not  be 
given  to  the  patient  for  use  at  home,  as  it  might  lead  to  the  formation  of  the 
cocaine  habit. 

d.  In  those  cases  in  which  the  cocaine  application  stops  the  pain,  the  "gen- 
ital areas"  in  the  nose  should  be  cauterized  by  a  rhinologist,  that  the  reflex 
feature  of  the  dysmenorrhoea  may  be  cured  or  relieved  for  some  months. 

Treatment  Between  the  Menstrual  Periods. 

After  the  pain  is  relieved  for  that  menstrual  period,  then  comes  the  ciuestion 
of  treatment  in  the  interval,  to  prevent  or  diminish  the  pain  of  succeeding 
periods. 

In  the  virgin  a  local  examination  is  not  called  for  at  first  in  the  absence 
of  decided  local  symptoms  between  the  menstrual  periods.  The  first  thing  to 
do  is  to  put  the  patient  on  a  regimen  of  general  measures  and  internal  treat- 
ment that  will  put  her  in  first-class  general  health. 

1.  General  Measures.  The  general  measures  are  directed  toward  improv- 
ing the  general  muscular  tone,  correcting  anemia  and  overcoming  constipa- 
tion. They  have  been  given  in  detail  when  speaking  of  the  treatment  of 
amenorrhoea  (page  854). 

2.  Internal  Treatment.  The  patient  is  placed  on  some  good  iron  tonic 
(Formulae),  with  or  without  the  addition  of  arsenic  or  strychnine  or  quinine, 
as  thought  best.  She  is  given  also  such  other  medicines  as  are  indicated  by 
special  symptoms  present — e.  g.,  by  indigestion  or  cough,  or  sleeplessness  or 
neuralgias.  Remember  that  in  gouty  or  rheumatic  patients,  dysmenorrhoea 
is  sometimes  much  relieved  by  remedies  directed  towards  overcoming  the 
nutritional  disorder  manifested  by  the  gout  or  rheumatism.  Laxatives  also 
are  important  when  there  is  any  tendency  to  constipation.  Give  some  tonic 
laxative  (Formulae)  in  sufficient  doses  to  give  one  or  two  good  bowel  move- 
ments daily. 

Some  antispasmodics-  liave  a  particular  effect  in  overcoming  menstrual 
pain.  Decided  benefit  is  often  secured  by  the  viburnum  preparations  pre- 
viously mentioned,  given  in  moderate  doses,  tliroe  times  daily  continuously 
and  increased  to  every  four  or  six  hours  during  the  flow.  Apiol  is  useful, 
especially  when  the  dysmenorrhoea  is  accompanied  with  scanty  menstrual 
flow.  It  may  be  prescribed  in  pill  form  in  doses  of  8  to  5  gr.  in  ready- 
filled  capsules.  The  active  principle  known  as  apioline  is  supplied  in  capsules 


DYSMENORRHOEA  IN  THE  VIRGIN  879 

containing  three  minims  each.  These  are  very  convenient  and  in  some  cases 
seem  to  be  active.  Potter  states,  however,  that  the  capsules  of  foreign 
make  are  unreliable  and  are  usually  inert.  If  there  is  excessive  flow, 
the  ergotin  and  cannabis  Indiea  capsules  may  be  used  (see  Styptics  under 
Formulae).  These  are  administered  continuously  for  some  months.  The 
other  preparations  used  especially  for  excessive  menstruation,  stypticin  and 
styptol  (page  865),  have  a  tendency  also  to  diminish  the  menstrual  pain. 
Two-drop  doses  of  tincture  of  Pulsatilla,  given  three  times  daily  for  several 
days  before  the  flow,  has  removed  dysmenorrhoea  in  several  cases. 

Many  other  preparations  belonging  to  the  general  class  of  antispasmodics, 
and  mentioned  in  works  on  materia  medica  and  therapeutics,  have  been  used 
from  time  to  time  for  dysmenorrhoea — with  marked  relief  to  some  patients 
and  with  no  relief  to  others.  As  a  general  proposition,  those  remedies  which 
are  beneficial  in  neuralgias  are  beneficial  also  in  dysmenorrhoea.  Thyroid 
extract  has  been  used  with  benefit  in  some  series  of  cases — one  series  showing 
marked  benefit  in  80  per  cent,  of  the  eases. 

3.  Intranasal  Examination.  In  cases  where  there  are  any  nasal  symptoms, 
and  also  in  the  cases  relieved  by  intranasal  applications,  a  rhinological  ex- 
amination should  be  made.  If  some  nasal  disease  is  present,  the  removal  of  it 
may  so  improve  the  menstrual  pain  that  the  patient  is  saved  much  suffering 
and  is  spared  the  embarrassment  of  a  pelvic  examination. 

4.  Pelvic  Examination  to  determine  local  lesion.  If  there  is  no  decided 
benefit  from  the  measures  already  mentioned  after  two  or  three  menstrual 
periods,  or  at  any  time  if  severe  local  symptoms  develop,  the  patient  should 
be  examined  to  determine  if  there  is  any  local  lesion.  The  details  of  the 
examination  of  a  virgin  have  been  given  (page  74).  In  many  cases  it  is 
best  to  make  the  examination  under  anesthesia,  for  the  reasons  there  stat- 
ed. When  examining  a  patient  under  anesthesia  for  dysmenorrhoea  or  for 
menorrhagia,  preparation  should  be  made  for  dilatation  and  curetment,  so 
those  therapeutic  measures  could  be  at  once  carried  out  under  the  examina- 
tion-anesthesia should  the  examination  reveal  a  condition  requiring  it.  Also, 
if  a  retrodisplacement  is  found,  an  attempt  to  correct  it  by  manipulation  may 
be  made  carefully  Avhile  the  patient  is  under  the  anesthetic. 

The  subsequent  treatment  will  depend,  of  course,  upon  the  conditions  found 
on  examination.  If  there  is  backward  displacement  of  the  uterus,  treatment 
for  that  is  required  (page  603)  ;  if  there  is  a  fibroid  tumor  of  the  uterus,  the 
treatment  is  for  that  (page  637)  ;  if  there  is  pelvic  tuberculosis,  the  treatment 
is  for  that,  as  indicated;  if  the  trouble  is  neurotrophic  dysmenorrhoea,  that 
must  receive  the  proper  attention,  and  so  down  the  list  of  possible  conditions. 
The  treatment  for  these  various  conditions  will  be  found  in  the  appropriate 
chapters. 

The  condition  styled  neurotrophic  dysmenorrhoea  belongs  especially  to 
this  chapter.  The  local  measures  of  treatment  for  this  condition  are,  in  gen- 
eral, measures  directed  toward  overcoming  the  stenosis  and  removing  an  un- 
healthy endometrium,  with  such  nutritional  change  as  would  necessarily  follow 


880  DISTURBANCES  OF  FUNCTION 

this  instrumentation.  I  will  mention  these  measures  as  a  continuation  of  the 
treatment  of  the  dysmenorrhoea  in  cases  where  no  more  marked  local  lesion 
is  found. 

5.  Thorough  Dilatation  and  Curetment  under  Anesthesia.  As  previously 
explained,  this  should  as  a  rule  be  the  first  local  measure  employed  in  the 
virgin,  as  it  is  not  ad^dsable  to  employ  any  local  treatment  unless  it  is  of 
such  character  that  it  will  have  some  decided  effect.  If  the  patient  is  to  be 
anesthetized  for  examination,  preparation  should  be  made  so  that  dilata- 
tion and  euretment  could  be  carried  out  at  the  same  time  if  found  ad\'isable. 
I  think  the  euretment  is  important,  for  it  enhances  the  nutritive  effect  of 
the  dilatation — and  the  benefit  from  the  procedure  is  due  to  its  nutritive  ef- 
fect on  the  uterine  tissues  as  well  as  to  the  removal  of  obstruction.  The  de- 
tails of  this  operation  have  been  given  (pages  571  to  582). 

If  the  patient  is  engaged  to  be  married  soon,  the  examination  under  anes- 
thesia with  the  dilatation  and  euretment  should  not  ordinarily  be  carried 
out.  Wait  until  several  months  after  marriage  before  emplojdng  any  local 
measures.  In  the  meantime  pregnancy  may  take  place,  and  that  will  do  more 
toward  a  permanent  cure  of  the  trouble  than  the  most  radical  operative 
measure.  The  marked  effect  of  pregnancy  in  these  cases  of  neurotrophic 
dysmenorrhoea  is  an  additional  indication  that  it  is  largely  a  nutritional 
trouble.  Pregnancy  exercises  a  most  profound  influence  upon  the  nutrition 
of  the  uterus,  both  of  the  muscular  tissue  and  of  the  mucosa.  It  has  been 
argued  that  pregnancy  and  parturition  produce  the  marked  curative  effect 
in  these  cases  by  overcoming  the  stenosis.  Without  doubt  it  does  overcome 
the  stenosis  better  than  any  other  known  measure,  but,  as  has  already  been 
explained,  the  stenosis  is  only  one  feature  of  the  trouble  and  the  removal 
of  the  stenosis  alone  does  not  always  effect  a  cure. 

We  may  confidently  expect  considerable  relief  from  thorough  dilatation 
and  euretment  in  the  great  majority  of  the  cases.  The  duration  of  the  im- 
provement is  variable.  In  a  majority  of  the  cases  there  is  a  return  of  the 
trouble  after  periods  varying  from  a  few  months  to  several  years,  though 
it  usually  does  not  become  so  severe  as  it  formerly  was.  In  95  cases,  reported 
by  H.  A.  Kelly,  32  were  relieved  (19  completely  and  14  largely),  with  no 
return  of  the  trouble — the  period  of  observation  extending  from  one  to 
twelve  years;  in  7  cases  there  was  relief  for  a  period  varying  from  one  to 
nine  years,  the  dysmenorrhoea  finally  returning;  in  28  cases  there  was 
relief  for  a  few  months,  but  the  dysmenorrhoea  returned  within  a  year;  and 
in  the  remaining  28  cases  there  "was  no  relief. 

With  the  dilatation  and  euretment  in  these  cases,  I  think  it  Avell  to  pack 
the  dilated  cervix  firmly  with  gauze  and  leave  the  packing  in  place  for  forty- 
eight  hours,  so  as  to  hold  the  internal  os  well  open  until  tlie  reparative 
infiltration  begins,  in  order  that  the  dilatation  may  be  made  as  prolonged  as 
possible.  Along  with  this  local  treatment  and  folloAving  it,  the  various  gen- 
eral measures  previously  recommended  should  ])e  used. 

In  order  to  make  the  dilatation  more  lasting,  II.  D.  Frye  advocated  the 


DYSMENORRHOEA  IN  THE  VIRGIN  881 

immediate  use  of  a  hard  rubber  drainage  plug  or  intra-uterine  stem.  He 
states  that  immediately  following  the  dilatation  and  euretment,  "a  Wylie 
drainage  plug  as  large  as  will  readily  pass  is  inserted  into  the  cervical  canal 
and  held  in  position  by  a  Smith  pessary.  For  a  number  of  years  I  was  ac- 
customed to  leave  the  plug  in  place  for  six  days,  but  following  the  sugges- 
tion of  Dr.  Wylie  I  now^  allow  it  to  remain  from  three  to  six  weeks  and  the 
result  is  better.  I  usually  keep  the  patient  in  bed  two  or  three  weeks  after 
operation,  and,  if  no  discomfort  be  experienced,  permit  her  to  get  up  and  go 
around,  wearing  the  plug  several  weeks  longer.  I  believe  the  use  of  the  hard 
rubber  drainage  plug  does  much  to  add  to  the  permanency  of  the  relief  ob- 
tained. When  retained  sufficiently  long,  it  causes  the  formation  of  a  cica- 
tricial ring  of  tissue  at  the  point  of  constriction,  which  insure  patulency.  I 
have  not  seen  any  bad  results  follow  its  use.  In  a  few  cases  it  causes  pain, 
and  on  that  account  must  be  removed  sooner  than  the  specified  time."  It 
must  be  kept  in  mind,  however,  that  w^hen  we  leave  a  foreign  body  in  the 
uterus  for  several  days,  particularly  immediately  after  opening  up  the  lymph 
spaces  by  euretment,  we  take  great  risk  of  causing  inflammatory  trouble, 
which  may  extend  to  tubes  and  become  far  more  serious  than  the  menstrual 
pain.    In  exceptional  cases  one  may  be  justified  in  taking  this  risk. 

The  cases  which  are  particularly  amenable  to  dilatation  are,  of  course, 
those  in  w^hich  the  obstructive  feature  is  prominent — i.  e.,  the  pain  is  severe 
and  cramp-like,  is  most  severe  just  as  the  flow  is  starting  and  largely  disap- 
pears when  the  flow  is  well  established.  When  there  is  a  tendency  to  later 
return  of  the  obstructive  features  of  the  dysmenorrhoea,  then  is  the  time  for 
the  use  of  partial  dilatation  or  electricity — or  stem  pessary  in  suitable  cases. 

6.  Partial  Dilatation  of  the  Cervical  Canal  in  the  Office.  This  is  rarely  ad- 
visable in  the  virgin  for  the  reason  that  in  such  a  patient  it  is  difficult,  pain- 
ful, ineffective  and  subjects  the  girl  to  a  pelvic  examination  without  much 
chance  of  benefit.  As  a  rule,  when  the  measures  previously  mentioned  fail, 
it  is  better  to  give  the  patient  an  anesthetic  and  dilate  thoroughly  and  curet 
as  above  explained.  Occasionally,  however,  in  an  unmarried  woman  this  par- 
tial dilatation  is  practicable  and  gives  much  relief. 

The  patient  is  placed  in  the  Sims  posture,  the  Sims  speculum  introduced, 
the  cervix  caught  and  brought  into  view,  and,  with  the  antiseptic  precau- 
tions necessary  in  all  intra-uterine  work,  the  graduated  metal  dilators  (Fig. 
101)  are  introduced  into  the  cervical  canal  and  past  the  internal  os — begin- 
ning Avith  the  smallest  size  that  the  canal  will  accommodate  and  passing  to 
the  largest.  After  dilatation  the  vagina  is  again  cleansed  with  the  antisep- 
tic solution,  the  speculum  removed  and  the  patient  directed  to  lie  doAvn  for 
a  time  after  she  gets  home  and  to  be  rather  quiet  the  remainder  of  the  day. 
This  dilatation  is  made  each  month  just  before  the  menstrual  time.  It  is  well 
to  dilate  four  or  five  days  before  the  fiow  is  expected  and  then  again  the 
day  before  the  flow.  The  closer  the  dilatation  to  the  beginning  of  the  flow, 
the  better  the  effect,  but,  if  one  waits  until  the  day  before  the  expected  flow 
for  the  first  dilatation,  the  flow  may  come  a  day  or  two  too  soon,  and  thus  the 
dilatation  is  missed  entirely. 


882 


DISTURBANCES  OF  FUNCTION 


7.  Stem  Pessary  or  Wire  Spring.  Like  partial  dilatation,  this  is  not  ap- 
plicable in  most  cases  of  clysmenorrhoea  in  the  virgin  until  after  the  cervix 
has  once  been  thoroughly  dilated  under  anesthesia. 

In  the  exceptional  cases  in  which  partial  dilatation  is  practicable  and  ef- 
fective temporarily,  but  must  be  repeated  every  month,  the  stem  pessary  or 
the  wire  spring  may  be  used  to  maintain  the  dilatation.  The  use  of  the  stem 
pessary  must  be  attended  with  great  caution.  It  was  formerly  used  fre- 
quently and  led  to  serious  pelvic  inflammatory  trouble  in  many  cases.  The 
harmful  results  Avere  so  frequent  that  the  use  of  the  stem  pessary  was  prac- 
tically dropped  by  careful  workers.    Later  it  was  found  that  in  certain  ex- 


Fig.  708. 
stem  pessary 


Stem  Pessaries;     u,  Outerbridge's  cervical  spring;  b,  liard-rubber  stem  pessary; 


c,  aluminum 


ceptional  cases  nothing  would  take  its  place,  and  that  in  these  carefully  se- 
lected cases  and  under  proper  technique  it  could  be  used  with  comparatively 
little  risk. 

Its  field  of  usefulness  is  to  overcome  the  obstruction  or  stenosis  in  those 
cases  without  other  pelvic  lesion  and  in  which  this  feature  causes  much  suf- 
fering in  spite  of  the  employment  of  less  undesirable  measures.  As  was  well 
emphasized  by  J.  IT.  Car.stens,  who  has  done  much  to  popularize  the  proper 
use  of  the  stem  pessary,  it  must  never  be  used  in  a  case  where  there  has  been 
any  tubal  or  ovarian  or  other  form  of  periuterine  inflammation,  or  when 
there  are  adhesions.   This  is  very  important,  for  the  use  of  a  stem  pessary  in 


DYSMENORRHOEA  IN  THE  VIRGIN  883 

such  cases  may  lead  to  serious  results.  Active  inflammation  in  the  uterus 
should  also  be  excluded.  The  use  of  the  stem  pessary  in  the  virgin  has  also 
the  same  objections  that  hold  for  partial  dilatation  or  any  other  local  treat- 
ment. Its  use  should  as  a  rule  be  reserved  for  those  cases  in  which  the  severe 
pain  returns  after  thorough  dilatation  and  curetment  under  anesthesia.  In 
the  married  woman,  where  the  objection  to  local  treatment  is  not  present 
and  where  also  the  cervix  is  likely  to  be  softer  and  more  easily  dilatable,  it  is 
more  frequently  advisable,  along  with  partial  dilatation,  as  a  treatment  pre- 
ceding thorough  dilatation  under  anesthesia.  The  cases,  however,  must  be 
carefully  selected,  as  previously  pointed  out.  A  foreign  body  remaining  in 
the  uterus  for  weeks  at  a  time  is  a  hazardous  condition,  and  such  treatment 
should  be  employed  only  with  a  definite  understanding  of  the  indications 
and  contra-indications,  and  then  only  in  cases  when  the  advisability  of  this 
treatment  rather  than  some  other  is  clearly  established. 

It  must  be  kept  in  mind  also  that  other  therapeutic  measures  must  also  be 
used,  as  indicated  by  the  conditions  present.  The  established  effect  of  the  stem 
pessary  is  simply  to  overcome  the  stenosis — though  it  is  possible  that  it  has 
some  stimulating  effect  on  the  local  nutrition  and  on  the  muscular  develop- 
ment (Carstens). 

The  pessary  is  applied  after  partial  dilatation  (page  881)  and  under  the 
same  strict  antiseptic  precautions  used  in  sounding  the  uterus  (page  87). 
The  preferable  time  to  apply  it  is  a  few  days  before  the  menstrual  flow.  If 
the  menstrual  pain  for  that  period  is  relieved,  the  pessary  may  be  left  in 
place  continuously  for  some  months,  providing  no  symptoms  of  irritation  ap- 
pear. The  patient  should  take  a  mild  antiseptic  douche  every  day  or  two  to 
prevent  the  possible  growth  of  germs  in  the  vagina  that  might  ascend  along 
the  open  cervical  canal.  The  intra-uterine  stem  should  always  have  openings 
or  grooves  along  which  the  uterine  secretion  may  freely  escape.  Useful 
forms  are  shown  (Fig.  708).  Outerbridge's  intra-cervical  spring  tends  to  hold 
open  the  canal  without  occupying  much  of  the  lumen.  A.  H.  Goelet,  also,  ad- 
vocates the  use  of  the  intra-uterine  stem  pessaries  and  illustrates  a  glass 
stem  with  a  hollow  center  and  a  flange  at  the  bottom,  to  be  held  in  place  by 
vaginal  gauze  packing.  He  states  that  "it  is  never  kept  in  the  uterus,  how- 
ever, for  a  longer  period  than  one  week,  and  during  that  time  the  patient  is 
confined  to  bed." 

8.  Electricity.  Intra-uterine  applications  of  electricity  may  give  consider- 
able relief  in  cases  where  the  trouble  returns  after  the  cervical  canal  has  been 
once  thoroughly  dilated. 

The  application  of  electricity  may  be  carried  out  along  with  the  partial 
dilatation  just  before  menstrual  periods,  the  electrode  being  used  to  effect 
the  dilatation  of  the  cervix.  With  the  galvanic  current,  use  the  negative  pole 
in  the  uterus,  under  the  antiseptic  precautions  necessary  in  all  intra-uterine 
treatment.  The  electrode  may  be  used  to  dilate  the  canal.  Introduce  the 
small  size  electrode  (page  354)  as  far  as  it  will  pass  easily  and  then  turn  on 
the  current,  making  the  internal  electrode  the  negative  pole.    Use  a  weak 


gg4  DISTURBANCES  OF  FUNCTION 

current,  about  10  to  15  milliamperes.  Make  a  steady  gentle  pressure  on  the 
electrode,  and  as  the  tissues  relax  about  the  electrode  it  passes  further  and 
further  along  the  canal  until  it  extends  past  the  internal  os.  Then  use  the 
larger  sizes  until  the  cervix  is  well  dilated.  Then  an  intra-uterine  applica- 
tion of  the  electricity  is  made,  using  15  to  20  m.  a.  at  first  and  continuing 
the  application  five  to  ten  minutes.  The  applications  are  given  once  or  twice 
weekly.  If  no  result  is  observed  from  this,  the  strength  is  increased  to  30 
or  40  or  50  m.  a.  If  there  is  a  tendency  to  menorrhagia  as  well  as  dysmenor- 
rhoea,  it  is  well  to  follow  the  employment  of  the  negative  pole  with  the  em- 
ployment of  the  positive  pole  for  5  to  10  minutes.  In  cases  that  do  not  do 
well  under  the  negative  pole,  it  is  weU  to  employ  the  positive  pole  altogether. 
Some  cases  do  better  under  the  faradic  current,  and  Avhen  one  method  does 
not  suffice  the  various  other  methods  may  be  tried. 

Electricity  has,  of  course,  the  dangers  and  contra-indications  common  to 
other  forms  of  intra-uterine  treatment.  It  has  an  admirable  effect  in  some 
cases,  while  in  other  cases  there  is  apparently  no  effect.  It  has  given  relief 
in  many  obstinate  cases,  and  is  worthy  of  trial  in  those  cases  where  there  is 
no  objection  to  vaginal  and  intrauterine  instrumentation.  It  is  useful  also  in 
certain  cases  of  that  most  obstinate  form  of  menstrual  pain — viz.,  men- 
braneous  dysmenorrhoea.  L.  H.  Dunning  relates  a  case  which  persisted  in 
spite  of  a  course  of  local  applications,  divulsion  and  curetment,  abdominal 
section  with  breaking  of  adhesions,  and  excision  of  a  diseased  ovary  and 
ventro-suspension,  but  finally  yielded  to  intra-uterine  applications  of  elec- 
tricity— 20  to  50  m.  a.  negative  pole  for  five  minutes,  and  the  current  slowly 
turned  off  and  then  on  again  with  positive  pole  for  five  minutes.  This  was 
repeated  twice  weekly.  The  first  menstruation  after  the  applications  showed 
less  pain.  At  the  second  the  membrane,  which  before  had  been  a  cast,  was 
reduced  to  shreds.  After  the  third  menstruation  no  membrane  passed.  The 
report  was  made  four  months  later,  at  which  time  there  had  been  no  return 
of  the  trouble,  which  before  had  been  so  severe  and  persistent  in  spite  of  all 
measures  that  the  patient  meditated  suicide.  The  electricity  was  continued 
two  or  three  times  monthly  as  a  preventive  against  recurrence.  In  the  dis- 
cussion, L.  R.  Brown  reported  a  case  of  membraneous  dysmenorrhoea  which 
resisted  repeated  thorough  dilatation  and  curetment,  and  the  patient's  suf- 
fering was  so  severe  that  she  was  a  nervous  wreck.  As  a  last  resort  he  used 
electricity — galvanic  current,  positive  pole  in  the  uterus,  12  m.  a.  continued 
for  eight  minutes,  and  repeated  three  times  per  week.  At  the  first  menstrual 
flow  there  was  no  improvement.  At  the  second  menstruation  she  passed  no 
membrane,  and  after  that  the  improvement  was  continuous,  with  no  relapse 
during  the  several  months  the  patient  was  under  observation.  The  menstrual 
flow,  which  formerly  lasted  ten  days,  was  reduced  to  four  (effect  of  the  posi- 
tive pole). 

In  regard  to  choice  of  pole,  remember  that  the  positive  pole  has  a  con- 
stricting effect,  diminishes  congestion,  dries  the  tissues  about  the  electrode, 
and  hence  causes  the  electrode  to  stick  where  it  is.    It  is  not  suitable  for  di- 


DYSMENORRHOEA    IN   THE  VIRGIN 


885 


lating  a  canal.  Before  using  the  positive  pole  the  electrode  should  be  carried 
all  the  way  into  the  uterine  cavity.  The  negative  pole,  on  the  other  hand, 
increases  congestion,  softens  the  tissues  and  aids  in  dilating  the  canal  (see 
also  pages  356,  357). 

9.  Excision  of  Tissue  from  Internal  Os.  (Theilhaber  Operation).  The  cer- 
vix is  dilated  thoroughly,  and  curetment  is  carried  out  if  desired.  The 
cervix  is  then  split  laterally,  on  each  side,  to  near  the  internal  os.  Then  ■v\ath 
a  small  knife,  inserted  under  the  direction  of  the  finger-tip  carried  to  the 
internal  os,  a  small  wedge  of  tissue  is  removed  from  the  anterior  and  from 
the  posterior  portion  of  the  circulating  ring.  This  wedge  of  tissue  extends 
about  one-third  through  the  thickness  of  the  uterine  wall.  The  work  is  much 


A  B 

Fig.  709.  Splitting  the  Cervix  for  Dysmenorrhoea  (Dudley  operation).  A,  showing  the  sharp  bending  of 
the  canal  from  the  anteflexion  of  the  cer\ix;  B,  showing  the  unobstructed  exit  secured  by  splitting  the  posterior 
Up  of  the  cenix  and  sewing  it  open. 


facilitated  by  a  knife  of  special  design.  The  preliminary  incisions,  splitting 
the  cervix,  are  then  closed  by  sutures. 

This  removal  of  wedges  of  tissue  from  the  constricting  ring  at  the  inter- 
nal OS  enlarges  the  opening  and  overcomes  the  obstruction.  Series  of  cases 
have  been  reported  with  excellent  results  in  nearly  all  cases  as  far  as  reliev- 
ing the  obstruction.  I  have  employed  the  operation  with  satisfaction,  but 
prefer  the  Dudley  operation,  which  gives  greater  probability  of  permanently 
overcoming  the  obstruction.  The  small  wedge-shaped  grooves  left  by  the 
excision  of  tissue  in  the  Theilhaber  operation  are  likely  to  fill  up  ^vith  scar 
tissue  and  the  opening  again  become  small.  There  is  nothing  about  it  to  in- 
sure permanent  enlargement  of  the  opening. 

10.  Splitting  Cervix  and  Sewing  it  Open.    (Dudley  Operation— Fig.  709). 


886 


DISTURBANCES  OF  FUNCTION 


This  is  applicable  to  those  eases  of  anteflexion  of  the  cervix  in  which  the  se- 
vere menstrual  pain  persists  after-  thorough  dilatation  and  curetment  under 
anesthesia.  In  some  cases  in  which  the  cervical  anteflexion  is  particularly- 
marked  it  is  advisable  to  employ  this  as  the  primary  operative  procedure. 
The  steps  of  the  operation  are  as  follows : 

a.  The  cervix  is  dilated  thoroughly  and  the  uterus  curetted  in  the  usual 
way. 

b.  The  posterior  lip  of  the  cervix  is  then  split  longitudinally  up  to  the 


Fig.  710.  Dudley  Operation.  Dividing 
the  posterior  wall  |of  tiiecer\ix.  (Dudley 
— Practice  of  Gynecology.) 


Fig.  711.  Dudley  Operation.  The  posterior  wall  of 
cervix  divided  and  the  principal  suture  passed.  Before 
passing  this  suture  a  wedge-shaped  piece  of  tissue  is 
excised  from  the  cervix  on  each  side  of  tlie  wound,  as 
indicated  by  the  dotted  lines.  (Dudley- — Practice  of 
Gynecology.) 


vaginal  vault,  the  incision  being  carefully  continued  internally  up  to  and  past 
the  internal  os.  The  constricting  ring  about  the  internal  os  should  be  di- 
vided sufficiently  to  readily  admit  a  linger.  Care  is  necessary  to  avoid  cut- 
ting too  deeply  into  tlic  ulorino  wall  at  this  point,  for,  if  the  wall  is  cut 
through  and  the  peritoneal  cavity  opened,  there  is  danger  of  peritonitis. 
Ordinarily,  there  is  no  necessity  for  opening  the  peritoneal  cavity.    In  some 


DYSMENORRHOEA    IN   THE  VIRGIN 


887 


cases,  however,  the  posterior  peritoneal  pouch  comes  very  low  or  the  inter- 
nal OS  is  situated  unusually  high.  In  either  case,  it  may  be  advisable  to  de- 
liberately open  the  peritoneal  cul-de-sac  in  order  to  properly  complete  the 
operation.  The  division  of  the  intravaginal  portion  of  the  cervix  may  be  most 
conveniently  made  with  long  scissors  (Fig.  710).  The  careful  division  of  the 
ring  about  the  internal  os  is  made  with  a  bistoury  under  the  guidance  of  the 
finger. 

c.  A  wedge  of  tissue  is  then  cut  out  of  each  lip,  as  indicated  by  the  dotted 


Fig.  712.     Dudley  Operation.     The  operative  work  on  the  postenor  part  of  the  cer\ix  has  been  completed. 

Also,  the  redundant  portion  of  the  anterior  lip  of  the  cervix  has  been  excised,  and  sutures  passed  for  closing 

the  wound      (Dudley — Practice  of  Gynecology.)  x 

..  'J 
V. 

lines  in  Fig.  711,  so  that  each  of  the  two  cut  edges  will  fold  well  on  itself 
when  the  principal  suture  is  tied. 

d.  A  strong  silk-worm  gut  suture  is  then  passed  as  shown  in  Fig.  711.  This, 
when  tied,  folds  the  cut  surface  of  each  lip  upon  itself  in  such  a  way  that 
the  ends  (where  the  tenacula  are  caught  in  Fig.  711)  are  brought  into  the 
angle  of  the  wound,  and  this  tends  to  permanently  hold  apart  the  divided 
tissues  about  the  internal  os.  Before  this  main  suture  is  tied,  however,  sec- 
ondary sutures  of  catgut  should  be  passed  in  sufficient  numbers  to  close  the 
lateral  portions  of  the  wound  and  prevent  any  hemorrhage.   The  main  suture 


DISTURBANCES  OF  FUNCTION 

is  then  tied,  and  lastly  the  secondary  sutures.  It  is  important  to  pass  the 
sutures  deeply  enough  to  catch  the  bulk  of  the  divided  tissue  to  prevent  rub- 
sequent  oozing.  In  one  of  my  cases  persistent  oozing  followed  the  operation 
and  this  increased  after  several  hours  to  a  flow  of  blood,  which  firm 
vaginal  packing  failed  to  stop  and  which  affected  the  patient's  pulse,  and 
assumed  such  serious  proportions  that  I  was  called  to  the  hospital  in  the  mid- 
dle of  the  night.  I  placed  the  patient  in  Sims'  posture,  removed  all  the  pack- 
ing and  passed  two  or  three  strong  catgut  sutures  deeply  through  the  cer- 
vix in  such  a  way  as  to  effectually  constrict  all  the  tissue  from  which  the 
bleeding  might  come.  This  was  done  without  anesthesia  and  without  disturb- 
ing the  other  sutures.  This  stopped  the  bleeding  and  the  patient  conva- 
lesced without  further  trouble. 

e.  In  cases  where  the  anterior  lip  of  the  cervix  is  very  long  it  may  be  ad- 
visable to  shorten  it  so  as  to  allow  the  cervix  to  better  assume  its  normal 
backward  direction,  instead  of  being  again  bent  forward  by  pressure  of  the 
posterior  vaginal  wall.  This  is  accomplished  by  excising  the  redundant  por- 
tion of  the  anterior  lip  and  closing  the  resulting  raw  surface  by  sutures 
passed  transversely,  as  shown  in  Fig.  712.  This  draws  a  good  wedge  of 
tissue  into  the  angle  between  the  cervix  and  corpus  uteri  and  tends  to  push 
the  cervix  back  toward  its  proper  direction. 

11.  Abdominal  Incision  of  Uterus.  This  method  (proposed  by  Dr.  C,  W. 
Barrett)  consists  of  opening  the  abdomen  by  regular  supra-pubic  incision, 
making  a  longitudinal  incision  through  the  posterior  wall  of  the  uterus  at 
the  internal  os,  spreading  this  incision  laterally  so  that  it  extends  trans- 
versely and  then  suturing  it  in  this  position.  It  accomplishes  enlargement  of 
the  internal  os  and  consequent  relief  of  the  obstruction.  As  a  rule,  however, 
the  patient  may  be  sufficiently  relieved  without  subjecting  her  to  the  danger 
of  abdominal  section.  When  the  abdomen  must  be  opened  on  account  of  ac- 
companying disease  of  the  adnexa  or  persistent  retrodisplacement  of  the 
uterus,  then  this  method  of  enlarging  the  internal  os  and  correcting  the  for- 
ward flexion  of  the  cervix  may  be  considered. 

12.  Operations  for  Diseased  Adnexa.  Of  course,  where  there  is  tubal  or 
ovarian  or  other  form  of  peri-uterine  disease,  that  should  receive  proper 
treatment,  operative  or  otherwise.  In  many  cases,  painful  menstruation  is 
simply  a  symptom  of  some  such  pelvic  disease,  and  is  relieved  by  removal  of 
the  same.  In  membraneous  dysmenorrhoea,  also,  search  should  be  made  for 
chronic  ovarian  or  tubal  disease. 

The  removal  of  practically  normal  ovaries  or  ovaries  that  are  not  seriously 
damaged,  for  the  relief  of  dysmenorrhoea,  is  to  be  most  strongly  condemned. 
There  are  many  things  that  are  far  worse  than  some  pain  for  a  few  days  each 
month,  and  the  removal  of  both  ovaries  in  a  young  woman  is  one  of  them. 
Pain  may  be  relieved  temporarily  l)y  some  of  the  various  palliative  meas- 
ures already  described,  and  then  there  is  always  the  possibility  that  the  pain 
will  diminish  or  cease  from  the  lapse  of  time  and  the  continual  employment 
of  therapeutic  measures.    But  when  the  ovaries  are  once  removed  they  are 


DYSMENORRHOEA  IN  THE  VIRGIN  gg9 

gone  irrevocably,  and  in  a  certain  proportion  of  such  cases  the  last  condition 
of  such  patient,  mentally  and  physically,  is  worse  than  death  itself.  Not  that 
the  removal  of  the  functuating  ovaries  in  a  young  woman  necessarily  or  al- 
ways has  such  a  marked  mental  and  physical  effect,  but  in  certain  cases  it 
has,  and  we  can  never  be  certain  that  such  will  not  be  the  result  in  the  par- 
ticular case  under  consideration.  Of  course,  it  is  possible  that  there  may  be 
certain  rare  cases  in  which,  in  spite  of  every  other  measure,  the  patient's  suf- 
fering from  menstruation  is  such  as  to  justify  this  risk,  but  I  have  never 
met  such  a  case. 

(B.)     DYSMENORRHOEA  IN  THE  MARRIED  WOMAN. 

Causes. 

This  may  be  due  to  any  of  the  twelve  conditions  already  described  as 
causes  of  dysmeuorrhoea  in  the  virgin.  It  may  be  due  also  to  one  of  the  fol- 
lowing additional  conditions : 

13.  Infected  endometritis,  acute  or  chronic. 

14.  Salpingitis  (acute  or  chronic)  or  one  of  the  other  forms  of  pelvic  in- 
flammation (oophoritis,  pelvis  cellulitis,  pelvic  peritonitis). 

A.  M.  Judd  reported  217  cases  of  endometritis,  accompanied  with  more  or 
less  laceration  of  cervix  and  pelvic  floor,  of  which  108  suffered  menstrual 
pain  and  109  did  not.  He  reports  also  177  with  diseased  tubes  and  ovaries, 
of  which  107  had  menstrual  pain  and  70  did  not.  . 

In  married  women,  membraneous  dysmeuorrhoea  must  be  distinguished 
from  early  abortion  and  extra-uterine  pregnancy,  in  both  of  which  condi- 
tions there  may  be  bloody  discharge,  with  much  pain  and  the  passage  of 
shreds  of  membrane.  If  this  happens  to  take  place  near  the  menstrual  time, 
the  patient  naturally  supposes  it  is  simply  a  menstruation  somewhat  delayed. 
In  membraneous  dysmeuorrhoea  there  is  usually  a  history  of  the  expulsion 
of  membrane  at  several  menstrual  periods,  whereas  with  abortion  there  is 
the  history  of  a  missed  menstruation  and  of  morning  sickness.  Also  the 
blood-clots  are  much  more  numerous  in  abortion,  and  with  the  membrane 
can  usually  be  found  a  small  sac  and  embryo.  The  bleeding  from  abortion 
persists  indefinitely  until  the  uterus  is  emptied,  whereas  in  membraneous 
dysmeuorrhoea  it  lasts  only  about  the  usual  menstrual  time.  Microscopic 
examination  of  an  expelled  membrane  or  of  shreds  removed  by  curetment 
in  abortion  shows  chronic  villi.  In  extra-uterine  pregnancy  there  is  no  pre- 
vious history  of  membraneous  dysmeuorrhoea  and  the  patient,  previously 
regular,  has  usually  gone  over  time  for  one  or  more  weeks.  The  pain  is  due 
to  intraperitoneal  bleeding  and  presents  the  characteristics  of  the  same. 

Treatment. 

The  treatment  during  the  flow  is  the  same  as  detailed  for  the  virgin 
(page  877).  The  treatment  in  the  interval  is  determined  by  the  local  trouble 
found  in  the  examination. 


890  DISTURBANCES  OF  FUNCTION 


INTERnENSTRUAL  PAIN. 

The  interesting  subject  of  pain  occurring  at  a  certain  time  every  month  in 
the  intermenstrual  period  has  received  considerable  attention  from  investi- 
gators, and  the  conclusion  has  been  reached  that  it  is  not  an  indication  of  any- 
particular  lesion,  but  is  a  pelvic  neuralgia  due  to  different  conditions  in  dif- 
ferent cases.  In  a  careful  study  of  the  subject  by  Rosner,  of  France,  it  was 
found  to  be  most  common  in  arthritic  subjects  and  was  supposed  to  be  due 
to  some  abnormal  action  of  the  ovaries.  The  periodicity  of  the  pain — that  is, 
its  appearance  each  month  a  certain  number  of  days  after  the  cessation  of 
the  menstrual  flow — is  probably  dependent  in  some  way  on  the  menstrual 
variations  in  blood  pressure,  and  generally  due  to  chemical  or  other  influence 
proceeding  from  the  ovaries  (page  806),  as  indicated  by  Van  de  Velde. 
He  shows  that  there  is  direct  enlargement  of  the  uterus  at  the  time  of  the 
intermenstrual  pain.  Malcolm  Storer,  who  reported  20  cases  of  his  own  and 
25  additional  cases  collected  from  literature,  found  that  in  10  of  the  cases 
there  was  a  marked  increase  in  the  leucorrhoea  at  that  time,  indicating  con- 
gestion of  the  uterus.  The  pain  usually  appears  about  midway  between  the 
menstrual  periods;  hence  it  usually  corresponds  with  the  lowest  part  of 
Stephenson's  menstrual  wave.  In  the  45  cases  reported  by  Storer  the  pain 
appeared  with  regularity  in  all  cases,  practically  every  month  unless  preg- 
nancy was  present.  In  22  cases  it  appeared  always  at  the  same  time  (in  most 
cases  about  two  weeks)  after  the  beginning  of  last  menstrual  flow.  In  13 
cases  there  was  a  variation  of  two  days,  in  four  cases  there  was  a  variation 
of  four  days,  and  in  two  cases  of  irregular  menstruation  it  would  appear  on 
a  certain  day  before  the  menstruation.  In  37  out  of  41  cases  the  pain  ap- 
peared from  twelve  to  sixteen  days  after  the  beginning  of  the  last  menstrua- 
tion and  in  20  of  them  it  began  exactly  on  the  fourteenth  day.  In  2  cases  it 
came  from  the  seventh  to  the  tenth  days,  in  1  case  on  the  seventeenth  day 
and  in  2  cases  on  the  eighteenth  day. 

As  to  treatment,  that  should  proceed  on  the  same  general  lines  as  the 
treatment  laid  down  for  menstrual  pain — i.  e.,  the  correction  of  general  con- 
ditions first,  and  the  employment  of  local  measures,  especially  of  operative 
measures,  only  in  cases  where  there  are  well-defined  indications  and  after 
other  measures  fail.  As  H.  C.  Coe  has  pointed  out,  the  assumption  that  in- 
termenstrual pain  is  always  associated  with  cystic  ovaries,  and  is  therefore 
an  indication  for  operation,  is  not  tenable.  Cystic  disease  of  one  or  both 
ovaries  is  found  in  some  cases,  but  the  diagnosis  of  cystic  ovaries  or  an  opera- 
tion for  the  same  must  always  be  based  on  distinct  examination  findings 
(page  888)  and  not  simply  on  periodic  pain. 

IRREGULAR  MENSTRUATION. 

The  menstrual  flow  may  come  too  soon,  the  interval  being  only  ten  days 
or  two  weeks.  Again,  the  flow  may  not  come  soon  enough,  running  over  time 


VICARIOUS  MENSTRUATION  g91 

from  one  to  two  weeks.  It  is  sometimes  difficult  to  determine  positively 
whether  the  irregular  flow  complained  of  is  really  menstruation  or  simply 
a  bloody  discharge  from  some  disease  of  the  vagina  or  uterus.  Unless  the 
bleeding  resembles  closely  the  menstrual  flow  in  character  and  onset  and  du- 
ration, it  should  be  regarded  as  a  pathological  discharge,  and  an  examina- 
tion should  be  made  to  determine  its  cause,  that  proper  treatment  may  be 
instituted. 


PRECOCIOUS     MENSTRUATION. 

Precocious  menstruation  is  the  appearance  of  menstruation  at  an  early  age. 
For  genuine  menstruation  to  take  place,  there  must  be  considerable  devel- 
opment of  the  genital  organs,  and  this  very  rarely  occurs  before  the  age  of 
ten.  Rare  cases  have  been  recorded  in  all  ages,  even  in  infancy.  It  has  been 
known  to  begin  in  infancy  and  continue  regularly.  There  is  usually  pre- 
cocious development  of  the  breasts  and  of  the  external  genitals. 

Great  care  is  necessary,  however,  in  establishing  the  fact  of  precocious 
menstruation  in  a  given  case.  Every  stain  of  blood  does  not  mean  menstrua- 
tion. The  blood  may  come  from  some  inflamed  or  irritated  area  or  ulcer,  or 
growth  on  the  vulva  or  in  the  vagina,  uterus,  rectum  or  bladder.  In  in- 
fants a  slight  bloody  uterine  discharge  occurs  not  infrequently  within  the 
first  week  or  two  after  birth.  It  is  not  a  menstrual  flow  and  it  soon  disap- 
pears. Again,  a  red  stain  on  the  diaper,  which  the  mother  supposes  to  be 
blood,  is  often  made  by  urates  from  a  concentrated  urine. 


VICARIOUS  MENSTRUATION. 

Vicarious  menstruation  is  the  discharge  of  blood  from  other  parts  of  the 
body  at  the  menstrual  time.  The  uterine  discharge  may  or  may  not  be  wholly 
or  partially  suppressed.  The  bleeding  usually  takes  place  from  the  nose  or 
from  some  open  sore,  though  it  may  come  from  almost  any  mucous  surface, 
such  as  the  lungs  or  stomach,  or  bladder  or  rectum.  Much  more  rarely  some 
area  of  the  cutaneous  surface  is  affected,  the  axilla  and  the  groin  being  the 
most  frequent.  At  the  affected  site  there  appears  an  ecchymosis  and  later 
a  distinct  flow  of  bloody  serum.  The  vicarious  flow  is  likely  to  be  irregular, 
appearing  only  at  some  menstrual  periods.  Allied  closely  to  this  is  the 
monthly  discharge  of  milk  from  the  breasts  sometimes  observed. 

Vicarious  menstruation  in  any  form  is  rare.  Goffe  records  a  very  interest- 
ing case  in  which  the  vicarious  discharge  came  alternately  from  the  nose  and 
the  axilla,  and  seemed  to  be  associated  with  periods  of  ungratified  sexual  de- 
sire. Vicarious  menstruation  is  found  principally  in  nervous  women  in  which 
there  is  imperfect  development  of  the  uterus  or  imperfect  performance  of  its 
functions.  The  treatment  consists  in  the  correction  of  any  peMc  disease 
present,  and  in  applications  to  the  site  of  bleeding  if  necessary. 


892  DISTURBANCES  OF  FUNCTION 


DYSPAREUNIA. 

The  two  principal  disturbances  of  sexual  intercourse  are  dyspareunia  (dif- 
ficulty in  coitus)  and  sexual  impotence  (absence  of  sexual  orgasm  in  coitus). 

Difficulty  in  coitus  (dyspareunia)  varies  from  a  slight  discomfort  hardly 
noticeable  to  pain  so  severe  as  to  make  coitus  unbearable. 

CAUSES. 

The  more  common  causes  of  dyspareunia  are  as  follows: 
1.  Some  Obstruction  to  Normal  Coitus,  a.  Imperforate  hymen. — In  such  a 
case  there  would  be  present  the  history  of  amenorrhoea  and  also  the  dis- 
turbances that  come  from  retained  menstrual  blood.  You  may  think  there 
would  be  a  history  of  no  coitus,  and  such  is  usually  the  case,  but  in  some 
cases  coitus  has  taken  place  through  some  adjacent  opening — for  example, 
through  a  dilated  urethra. 

b.  Organic  Stenosis  of  Vaginal  Orifice. — The  opening  is  large  enough  to 
permit  the  regular  escape  of  menstrual  blood,  but  it  is  not  large  enough  to 
permit  coitus.  The  obstructing  tissue  is  so  firm  that  it  does  not  rupture  as 
ordinarily  on  attempted  coitus.  This  obstruction  may  be  due  to  a  very  strong, 
firm  hymen,  or  to  some  distinct  malformation,  such  as  a  vaginal  septum  from 
double  vagina.  Usually  with  double  vagina,  each  vagina  is  large  enough  for 
coitus  or  the  septum  is  placed  so  far  to  one  side  that  it  does  not  interfere. 
But  it  may  be  so  placed  as  to  interfere  decidedly  with  coitus  and  to  require 
division.  Again,  an  organic  stenosis  here  may  be  due  to  scar-tissue  from  se- 
vere burn  or  other  injury,  or  from  laceration  in  labor,  with  extensive  scar- 
tissue  formation. 

c.  Spasmodic  Stenosis  at  Vaginal  Orifice. — In  some  cases  there  is  marked 
hyperesthesia  about  the  vaginal  orifice,  and  every  attempt  at  coitus  causes  un- 
bearable pain  or  causes  spasmodic  contraction  of  adjacent  muscles  to  such 
an  extent  that  coitus  is  impossible.  This  marked  hyperesthesia  may  be  due 
to  inflammation,  such  as  vulvitis  or  vaginitis,  or  it  may  be  due  to  sensitive 
abrasions  about  the  vaginal  entrance.  In  other  cases  it  is  due  to  that  pecu- 
liar condition  known  as  ''vaginismus,"  a  reflex  contraction  of  the  levator 
ani  and  adjacent  muscles  without  apparent  cause.  In  exceptional  cases  this 
is  so  severe  and  persistent  as  to  altogetlier  prevent  coitus. 

d.  Severe  Pain  on  Attempted  Intercourse. — There  is  no  stenosis  or  spasm, 
but  just  pain,  so  severe  that  coitus  is  impossible.  This  may  be  due  to  inflam- 
mation about  the  external  genitals  or  inflammation  witliin  the  pelvis. 

2.  Simple  Inflamed  Abrasions  About  the  Vulva.  Tliis  is  not  an  infrequent 
cause  of  much  suffering  immediately  after  marriage.  The  small  abrasions 
that  naturally  accompany  rupture  of  the  hymen  at  the  first  intercourse  may 
become  inflamed  after  a  day  or  two,  making  subsequent  coitus  painful.  This 
sometimes  causes  much  alarm  to  the  patient  and  her  husband,  who  fear  some 
serious  trouble.  The  treatment  is  abstinence  from  coitus  for  a  few  days,  Math 


DYSPAREUNIA  g93 

the  frequent  use  of  some  mild  antiseptic  wash  (1/2%'  car])olic  sohitionj,  fol- 
lowed by  drying  with  absorbent  cotton  and  the  use  of  a  soothing  ointment, 
such  as  carbolized  vaseline.  It  is  well  to  keep  the  parts  covered  with  a  pad 
of  absorbent  cotton,  to  keep  the  clothing  from  contact  with  the  painful  areas 
and  also  to  protect  the  abrasions  from  infection. 

3.  Venereal  Sores  (chancroid,  syphilitic).  These  abrasions  also  may  be 
found  soon  after  marriage  or  at  any  other  time.  Care  should  always  be  taken 
not  to  give  a  positive  prognosis  in  a  case  of  abrasion  or  sore  which  has  not 
yet  had  time  to  develop  its  characteristics. 

4.  Gonorrhoeal  Inflammation.  This  is  an  altogether  too  common  cause  of 
painful  coitus  in  the  first  few  weeks  following  marriage.  The  pain  may  be 
due  to  the  vulvar  inflammation,  or  to  the  urethritis  or  to  the  vaginitis,  or  to 
painful  abrasions  or  to  the  inflammation  of  the  vulvo-vaginal  gland  of  one  or 
both  sides. 

5.  Other  forms  of  inflammation  of  vulva  or  vagina,  or  vulvo-vaginal  glands. 

6.  Inflammation  of  uterus  (acute  or  subacute). 

7.  Inflammatory  lesions  around  the  uterus,  in  which  pain  is  caused  by  the 
impact  of  the  male  organ  or  by  the  sexual  congestion.  When  the  ovary  is 
prolapsed  into  the  cul-de-sac  and  bound  there  by  adhesions,  sexual  inter- 
course may  cause  much  pain.  I  recall  one  patient  in  whom  it  was  finally 
necessary  to  open  the  abdomen,  break  up  the  adhesions  and  fasten  up  the 
prolapsed  ovary  in  order  to  relieve  the  suffering  in  coitus.  In  the  more 
serious  pelvic  inflammatory  conditions,  this  is  frequently  a  prominent  symp- 
tom. 

8.  Retrodisplacement  of  the  uterus,  with  inflammation.  It  is  surprising 
how  much  displacement  of  the  uterus,  with  forward  projection  of  the  cervix 
and  apparent  blocking  of  the  vagina,  can  take  place  without  occasioning  any 
particular  disturbance  in  coitus.  But  if  inflammation  appears,  then  dys- 
pareunia  is  often  marked — much  more  so  than  from  the  same  amount  of  in- 
flammation without  displacement. 

9.  Bladder  or  rectal  diseases  occasionally  cause  painful  coitus,  particu- 
larly inflammatory  diseases. 

TREATMENT. 

P'he  treatment  of  dyspareunia  is  indicated  by  the  particular  condition 
present,  as  determined  by  a  careful  examination. 

1.  If  there  is  some  malformation  about  the  vaginal  orifice  (imperforate 
hymen,  thick  hymen,  septum  in  vagina,  organic  stenosis  of  vagina),  the  ob- 
struction must  be  removed  by  the  necessary  operative  measures. 

2.  If  coitus  is  interfered  with  by  tender  areas  about  the  vaginal  entrance, 
or  by  ulcers  or  by  hyperesthesia,  the  following  measures  may  be  employed : 

a.  Abstinence  from  sexual  intercourse  for  one  to  three  weeks. 

b.  Hot  vaginal  douches  once  or  twice  daily — medicated  or  unmedi- 

cated,  depending  upon  the  presence  of  discharge. 


g94  DISTURBANCES  OF  FUNCTION 

c.  Laxatives  as  needed.    Chronic  constipation  increases  the  conges- 

tion and  irritability  of  the  structures. 

d.  Some  sedative  ointment — for  example,  chloretone  ointment  (10%), 

applied  two  or  three  times  daily. 

e.  Bromides,  if  there  is  much  nervous  irritability  or  apparent  hyper- 

esthesia of  reflex  centers. 

f.  "When  intercourse  is  again  attempted,  the  patient  should  coat  all 

the  sensitive  surfaces  with  a  sedative  ointment.  The  chloretone 
ointment  above  mentioned  may  be  used  or,  if  that  is  not  effect- 
ive, an  ointment  containing  2  to  5  per  cent  of  cocaine. 

3.  If  the  vaginal  opening  is  too  small  or  there  is  the  spasmodic  condition 
known  as  vaginismus,  stretching  of  the  opening  is  to  be  employed  in  addition 
to  the  other  measures  just  detailed.  In  some  cases  the  tendency  to  spasm  may 
be  overcome  by  gradual  stretching  Avith  a  speculum  every  few  days  without 
anesthesia.  In  cases  of  organic  narrowing  it  is  advisable  to  pack  the  vagina 
in  order  to  hold  what  has  been  gained  and  to  aid  in  securing  relaxation.  If 
the  gradual  stretching  without  anesthesia  fails,  then  the  patient  should  be 
anesthetized  and  the  vaginal  opening  thoroughly  stretched.  If  the  opening 
does  not  stretch  well  or  the  tendency  to  spasm  is  marked,  it  is  well  to  divide 
the  constricting  structures  and  close  the  wound  over  them  by  sutures: 

The  treatment  of  the  other  organic  lesions  mentioned  under  causes  is.  taken 
up  in  detail  in  the  appropriate  chapters. 

SEXUAL  inPOTENCE. 

The  absence  of  strong  sexual  feeling  in  the  woman  during  coitus  does  not 
assume  the  serious  aspect  it  does  in  the  man,  with  whom  erection  is  necessary 
to  insemination  leading  to  pregnancy.  The  strong  sexual  feeling,  with  its 
consequent  orgasm,  in  the  woman  is  not  at  all  necessary  to  impregnation, 
though  it  increases  the  probability  of  impregnation.  From  the  history  of 
cases  of  sexual  disturbance  it  is  evident  that  many  otherAvise  normal  Avomen 
have  little  or  no  sexual  feeling  until  some  months  or  years  after  marriage — 
sometimes  not  until  after  one  or  more  children  are  born.  The  response  to 
sexual  excitement  apparently  groAvs  AAdth  the  proper  exercise  of  the  sexual 
functions.  Tliis  fact  is  important  and  may  be  used  to  prevent  discord  and 
disruption  in  families  Avhere  cither  the  husband  or  the  A\dfe  is  becoming  dis- 
satisfied and  despondent  because  it  is  felt  that  there  is  not  the  proper  sexual 
response. 

Again,  there  are  cases  in  Avhich  the  Avife  is  not  in  physical  condition  to  re- 
spond. She  lias  some  chronic  trouble  Avhich  so  saps  her  strength  that  she 
has  not  the  A'itality  for  this  function.  This  loss  of  strength  may  be  due  cither 
to  some  general  condition  or  to  some  local  condition,  or  to  both.  It  is  hardly 
necessary  to  name  the  A^arious  conditions.  They  comprise  the  whole  list  of 
debilitating  conditions,  both  general  and  local. 


STERILITY  895 

The  treatment  of  f3exiial  impotence  is  directed  toward  removing  any  local 
disease,  aud  toward  building  up  the  general  health  to  the  higliest  point — by 
a  long  course  of  tonics  (including  iron,  strychnia,  etc.),  by  change  of  environ- 
ment, and  by  rest  from  care  and  worry  and  overwork,  and  too  frequent  sexual 
intercourse.  The  rest  indicated  is  very  important,  for  the  things  mentioned 
tend  to  keep  the  patient  dragged  down  below  par  and  in  no  condition  to  re- 
spond buoyantly  and  vigorously  to  any  of  the  mental  or  physical  require- 
ments of  daily  life. 

STERILITY. 

Sterility  is  the  absence  of  pregnancy  under  circumstances  that  normally 
lead  to  pregnancy. 

It  is  said  that  about  10  per  cent  of  marriages  are  without  offspring,  and 
the  popular  impression  is  that  this  sterility  is  nearly  always  due  to  some 
defect  or  disorder  in  the  genital  organs  of  the  woman.  The  woman  receives 
almost  altogether  the  blame  for  the  inability  to  produce  offspring.  In  many 
eases  the  defect  is  with  the  woman,  but  in  many  other  cases  this  blame  is 
placed  upon  her  unjustly.  If  we  exclude  from  the  definition  of  sterility  those 
cases  in  which  the  failure  to  produce  offspring  is  due  to  early  abortions,  or 
to  prevention  of  conception,  then  sterility  is  in  a  large  proportion  of  the 
cases,  if  not  in  the  majority  of  them,  due  primarily  to  the  husband.  In  that 
large  class  of  cases  in  which  the  immediate  cause  of  the  sterility  is  gonor- 
rhoea! inflammation  involving  the  tubes  and  ovaries,  the  primary  cause  lies 
with  the  husband  and  on  him  must  rest  the  blame  for  the  childless  home. 

Sterility  is  sometimes  defined  as  the  inability  to  bring. forth  a  living  child, 
even  though  that  the  child  were  carried  to  full  time.  But  I  prefer  to  limit 
the  term  to  the  cases  of  absence  of  pregnancy.  This  is  sometimes  designated 
as  "absolute  sterility."  Therefore,  considering  sterility  from  the  gyneco- 
logical standpoint,  let  the  definition  be  "the  inability  to  become  pregnant." 
The  patient  may  have  had  children  or  abortions  in  former  years,  or  she  may 
not.  At  any  rate,  she  does  not  become  pregnant  now,  though  she  earnestly 
desires  to  be  so. 

CAUSES. 

In  order  to  assist  in  determining  the  exact  cause  of  the  sterility  in  the 
various  cases,  it  is  well  to  consider  what  is  necessary  that  a  normal  pregnancy 
may  take  place.  It  is  necessary  ordinarily  (a)  that  healthy  spermatozoa  be 
deposited  in  the  vagina,  (b)  that  the  spermatozoa  remain  healthy  and  pen- 
etrate into  the  uterine  cavity  and  into  the  Fallopian  tubes,  (c)  that  a  healthy 
ovum  be  formed  in  the  ovary,  (d)  that  it  find  its  way  into  the  Fallopian 
tube,  where  it  can  be  fertilized  by  a  spermatozoon,  (e)  that  the  fertilized 
ovum  pass  into  the  uterus,  and  (f)  that  it  find  there  an  endometrium  suit- 
able for  its  implantation  and  development. 

Some  of  these  conditions  are  not  always  absolutely  necessary.     At  least 


896  DISTURBANCES  OF  FUNCTION 

five  cases  of  conception,  with  labor  at  term,  have  taken  place  in  patients  where 
both  Fallopian  tubes  and  presumably  both  the  ovaries  were  removed.  Of 
course,  some  ovarian  tissue  was  left.  But  the  tubes  may  be  removed  and 
still  the  openings  in  some  cases,  without  doubt,  reopen  and  permit  the  ovum 
to  pass.  Fritsch  ligated  both  Fallopian  tubes  in  the  middle  with  silk  and 
still  pregnancy  followed  three  years  later.  Ashton  reported  the  occurrence 
of  pregnancy  in  the  cervix  following  removal  of  the  body  of  the  uterus  for 
fibromyomata,  showing  that  even  the  body  of  the  uterus  was  not  absolutely 
essential  to  pregnancy.  Again,  pregnancy  has  occured  in  cases  where  pen- 
etration of  the  male  organ  into  the  vagina  was  impossible,  showing  that  the 
spermatozoa  may  pass  from  the  external  genitals  up  to  the  uterus.  But 
these  are  all  very  exceptional  cases.  Ordinarily  each  of  the  conditions  men- 
tioned is  each  a  bar  to  pregnancy. 

Assuming  that  the  husband  furnishes  healthy  spermatoza,  the  sterility  may 
be  due  to  the  following  causes : 

1.  Some  Conditions  Interfering-  with  Coitus.  These  conditions  are  con- 
sidered under  ''dyspareunia''  (page  892). 

2.  Laceration  of  Pelvic  Floor.  When  there  has  been  a  marked  lacera- 
tion, the  vagina  may  be  so  relaxed  and  patulous  that  the  semen  is  not  re- 
tained in  contact  with  the  cervix  long  enough  for  the  spermatozoa  to  pass 
up  into  the  uterine  cavity. 

3.  Vaginitis  or  profuse  discharge  in  the  vagina  may  interefere  chemically 
with  the  vitality  of  the  spermatozoa  or  mechanically  with  their  progress  to, 
or  entrance  into,  the  cervix  uteri.  In  either  case  the  chance  of  pregnancy  is 
diminished. 

4.  Some  Obstruction  in  the  Cervical  Canal,  a.  Stenosis  of  external  os. — 
This  may  be  found  in  the  form  of  the  congenital  "pin-hole"  os  or  it  may  be 
due  to  scar-tissue  resulting  from  former  injuries. 

b.  Stenosis  at  internal  os. — This  may  be  due  to  scar-tissue,  but  it  is  more 
frequently  due  to  a  sharp  anteflexion  of  the  cervix.  It  is  often  combined  with 
a  long  pointed  cervix  and  the  ''pin-hole"  os  already  mentioned.  This  com- 
bination is  a  frequent  cause  of  sterility  in  women  who  have  never  been  preg- 
nant, and  it  is  usually  accompanied  with  dysmenorrhoea. 

c.  Discharge. — There  may  be  in  the  cervical  canal  an  excessive  secretion 
or  discharge  which  interferes  chemically  with  the  vitality  of  the  spermatozoa 
or  mechanically  with  their  journey  upward. 

5.  Some  Displacement  of  the  Uterus,  a.  Retrodisplaeement. — Retrodis- 
placement  of  the  uterus  may  throw  the  cervix  so  far  forward  that  the  sper- 
matozoa do  not  readily  enter  it. 

b.  Anteflexion. — Sharp  anteflexion  of  tlie  cervix  may  also  throw  the  cer- 
vical opening  too  far  forward. 

e.  Decided  Prolapse. — Prolapse  of  tlie  uterus  may  interrere  meclianically 
with  coitus  or  with  the  passage  of  tlie  spermatozoa  to  the  interior  o-f  the 
uterus. 

6.  Some  abnormal  condition  within  the  uterine  cavity,'  Avliich  iuterferes 


STERILITY  897 

with  the  passage  of  the  spermatozoa  to  the  tubes,  or  which  fails  to  furnish 
a  proper  place  for  the  implantation  and  nourishment  of  the  fertilized  ovum. 

a.  Simple  endometritis. 

b.  Infected  endometritis. 

e.  Tuberculosis  of  the  endometrium. 

d.  Malignant  disease  (carcinoma  or  sarcoma). 

e.  Fibromyoma. 

7.  Some  affection  of  the  Fallopian  tubes  which  interferes  with  the  entrance 

of  the  spermatozoa  into  the  tube  or  with  the  entrance  of  the  ovum  into  the 
tube,  or  with  the  passage  of  the  fertilized  ovum  from  the  tube  into  the  uterus. 

a.  Inflammation. — Inflammation  of  the  tube  is  the  most  frequent  cause  of 
sterility  from  tubal  disturbance.  This  may  be  very  slight — not  enough  to 
produce  symptoms  nor  physical  signs,  but  just  enough  to  cause  occlusion  of 
one  or  both  ends  of  the  tube.  It  may  vary  all  the  way  from  this  mild  form 
to  severe  inflammation  and  disorganization  of  the  tube,  with  extensive  exu- 
date and  adhesions  and  abscess  formation.  Salpingitis,  coming  on  after  the 
first  childbirth,  or  miscarriage,  because  of  inflammation  during  the  puer- 
perium  or  because  of  gonorrhoea,  infection  brought  by  the  husband,  who  was 
untrue  to  his  wife  during  her  confinement,  is  a  prolific  source  of  the  so-called 
"one  pregnancy  sterility." 

b.  Tuberculosis. — Tuberculosis  of  tubes  and  adjacent  structures. 

c.  Tumor. — A  tumor  of  the  tube  or  in  the  vicinity  of  the  tubes,  interfering 
with  their  functions. 

d.  Malformation  of  the  Tubes. — This  may  consist  in  atresia  of  one  or  both 
ends  of  the  tubes,  or  in  blind  passages  and  diverticula  into  which  the  ovum 
may  wander  and  lodge.  Or  there  may  be  abnormal  openings  in  the  wall  of 
the  tube  through  which  the  ovum  may  pass  out  into  the  peritoneal  cavity 
and  be  lost. 

8.  Some  affection  of  the  ovaries  that  interferes  with  their  function  to  such 
an  extent  that  healthy  ova  are  not  formed  or  are  not  discharged  in  such  a 
way  that  they  pass  into  the  Fallopian  tubes. 

a.  Inflammation. — Inflammation  of  the  ovary  may  be  present  in  some  of 
its  various  forms — infected  oophoritis,  simple  oophoritis,  cystic  ovary,  cir- 
rhotic ovary  or  an  ovary  covered  with  exudate  and  adhesions. 

b.  Tuberculosis  of  ovaries  and  vicinity. 

c.  Tumors  of  the  ovary. 

d.  Displacement  of  the  ovary. — This  may  be  so  marked  that  the  ova,  in- 
stead of  passing  into  a  Fallopian  tube,  where  they  would  be  fertilized,  pass 
into  the  peritoneal  cavity  and  perish. 

9.  Certain  operations — for  example,  removal  of  the  uterus  or  of  the  Fallo- 
pian tubes,  or  of  both  ovaries. 

10.  Douches,  which  may  interfere  chemically  or  mechanically  with  the 
process  of  impregnation. 

11.  General  Conditions.  The  general  health  may  be  so  poor  that  all  the  or- 


898  DISTURBANCES  OF  FUNCTION 

gans  of  the  body  are  in  too  poor  a  condition  to  properly  functionate,  the 
genital  organs  among  them.  This  is  seen  in  some  cases  of  marked  anemia  and 
emaciation,  and  general  depression.  On  the  other  hand,  it  is  present  at  times 
in  patients  who  are  inclined  to  stoutness.  The  effect  of  obesity  in  diminishing 
menstruation  has  been  mentioned,  and  it  sometimes  has  much  the  same  effect 
on  the  capacity  for  impregnation.  It  has  happened  that  sterility  came  on 
when  a  patient  accumulated  fat  and  disappeared  promptly  on  reduction  to 
her  usual  weight. 

DIAGNOSIS. 

A  couple  come  to  consult  you  because  they  have  no  children.  Your  prob- 
lem is  to  find  the  cause  of  the  sterility  in  this  particular  case.  If  the  husband 
is  an  intelligent  man,  he  will  speak  of  any  genital  disturbance  which  he  has 
had  that  might  have  a  bearing  on  the  subject.  If  no  explanation  is  made, 
it  is  to  be  assumed  that  the  husband  is  healthy,  though  this  assumption 
should  be  confirmed  as  soon  as  opportunity  occurs  of  questioning  him  when 
the  wife  is  not  present.  Gross  found  the  male  directly  at  fault  in  about  16 
per  cent  of  the  cases  of  sterility  and  De  Sinty  found  the  trouble  to  lie  with 
the  male  in  25  per  cent  of  the  cases.  The  chief  causes  in  the  male  were  im- 
potence, or  absence  of  semen  or  absence  of  living  spermatoza.  If  there  is  any 
question  as  to  the  ability  of  the  husband  to  perform  his  part  in  the  process 
of  impregnation,  a  specimen  of  the  semen  should  be  submitted  to  microscopic 
examination,  that  the  presence  or  absence  of  living  spermatozoa  may  be  posi- 
tively established. 

Assuming  that  the  husband  is  healthy,  the  wife  is  questioned  to  secure  the 
systematic  gynecological  history  and  to  bring  out  any  special  facts  that  may 
have  a  bearing  on  the  sterility.  The  history  may  point  decidedly  to  some 
serious  pelvic  disorders,  or  there  may  be  nothing  in  the  history  to  indicate 
that  the  pelvic  organs  are  other  than  normal.  A  thorough  pelvic  examina- 
tion is  then  made  to  determine  if  there  is  any  pathological  condition  in  the 
genital  tract. 

The  various  conditions  that  may  give  rise  to  sterility,  together  with  their 
diagnostic  points,  have  just  been  detailed  under  "causes." 

TREATMENT. 

1.  If  there  is  difficulty  in  coitus,  treatment  for  that  will  be  required.  This 
is  considered  in  detail  under  dyspareunia  (page  893). 

2.  There  may  be.  anteflexion  of  the  cervix,  with  stenosis  in  the  canal,  a  fre- 
quent cause  of  sterility  in  patients  who  have  never  been  pregnant.  Where 
sterility  results  from  this  condition,  the  treatment  is  dilatation  of  the  canal, 
and  for  this  there  are  three  methods,  as  follows: 

a.  Partial  Dilatation  without  Anesthesia. — The  details  of  this  procedure 
as  employed  for  sterility  are  the  same  as  described  under  Dysmenorrhoea, 
except  that  the  dilatation  is  made  immediately  after  each  menstrual  flow 


STERILITY  899 

instead  of  before  the  flow.  Just  after  menstruation  is  supposed  to  be  the 
most  favorable  time  for  impregnation,  so  the  canal  is  dilated  then  and  it  re- 
mains somewhat  dilated  for  a  week  or  so.  The  patient  is  directed  to  take  no 
douches  unless  there  is  a  troublesome  discharge.  If  there  is  a  discharge 
necessitating  douches,  a  saline  douche  (a  tablespoonful  of  table  salt  to  two 
quarts  of  warm  water)  should  be  used  and  the  douche  should  be  taken  in 
the  evening — not  in  the  morning.  No  antiseptic  douche  is  allowed  because  it 
interferes  with  impregnation.  This  treatment  may  be  repeated  after  each 
menstrual  flow  for  several  months,  until  pregnancy  takes  place  or  until  it  is 
apparent  that  no  result  is  to  be  accomplished  by  this  method. 

In  many  cases  more  radical  measures  are  necessary.  In  some  cases,  how- 
ever, the  simple  dilatation  just  described  carried  out  a  few  times  will  put 
the  parts  in  such  condition .  that  pregnancy  ensues,  and  it  is  worthy  of  trial 
in  all  cases  where  the  canal  dilates  readily  and  there  is  not  a  profuse  uterine 
discharge.  In  one  of  my  patients,  pregnancy  followed  a  single  such  treat- 
ment made  after  several  years  of  sterility. 

b.  Thorough  Dilatation  Under  Anesthesia. — The  patient  is  anesthetized, 
the  cervix  widely  dilated  and  the  interior  of  the  uterus  cureted.  The  curet- 
ment  is  advisable  in  practically  all  such  eases,  for  the  endometrium  is  usually 
not  entirely  healthy. 

This  thorough  dilatation  under  anesthesia  is  employed  in  cases  in  which 
the  previous  method  fails  to  produce  results.  It  is  advisable  as  the  primary 
treatment  in  those  cases  where  the  cervix  is  small  and  sensitive.  The  dilata- 
tion thus  secured  is  likely  to  persist  in  a  measure  over  several  months,  and 
thus  gives  a  good  chance  of  pregnancy. 

c.  The  Dudley  Operation. — This  is  explained  and  illustrated  under  Dysmen- 
orrhoea.  It  is  employed  for  the  purpose  of  permanently  overcoming  the  ob- 
struction in  cases  where  the  stenosis  tends  to  recur  after  wide  dilatation  un- 
der anesthesia. 

3.  There  may  be  inflammation  of  the  cervix,  Avith  discharge,  which  inter- 
feres with  the  vitality  or  upward  progress  of  the  spermatozoa.  Such  a  con- 
dition requires  the  treatment  for  endocervicitis  (see  chapter  VI). 

4.  Laceration  of  the  Cervix,  with  consequent  cystic  degeneration  and  dis- 
charge, may  be  present  and  requires  the  usual  measures  to  allay  the  inflamma- 
tion and  lessen  the  discharge.  If  these  palliative  measures  are  not  effective, 
the  cervix  should  be  put  in  better  condition  by  an  operation  for  repair — be- 
ing careful  in  the  denudation  to  leave  a  wide  cervical  canal,  so  that  there  will 
be  no  resulting  stenosis.  This  removes  the  chronically  inflamed  and  dis- 
charging surfaces,  and  thus  increases  the  chance  of  the  spermatozoa  being 
able  to  penetrate  into  the  uterus. 

5.  If  there  is  marked  chronic  endometritis,  that  must  receive  appropriate 
treatment — which  will  include  usually  a  thorough  curetment. 

6.  Retrodisplacement  of  the  uterus  may  be  present.  If  so,  it  requires  the 
treatment  detailed  in  chapter  VII. 

7.  Tumors  in  the  uterus,  or  elsewhere  in  the  pelvis,  must  be  removed  when 
it  is  at  all  probable  that  they  are  a  factor  in  the  sterility. 


900  DISTURBANCES  OF  FUNCTION 

8.  Pelvic  Inflammation  in  one  of  its  various  forms  may  be  found.  If  the 
inflammation  is  of  recent  origin  and  there  are  no  serious  symptoms,  employ 
palliative  measures.  If  the  pelvic  inflammation  is  improved  thereby,  these 
palliative  measures  may  be  kept  up  for  several  months  in  the  hope  that  na- 
ture will  repair  the  damaged  organs  sufficiently  to  restore  their  function.  For 
the  prognosis  in  regard  to  pregnancy  alter  pelvic  inflammation  see  page  728. 

In  chronic  pelvic  inflammation  the  chance  of  pregnancy  may  in  some  cases 
be  decidedly  increased  by  the  removal  of  the  disorganized  portions  of  the 
Fallopian  tubes  and  special  treatment  of  the  remaining  part.  The  special 
treatment  consists  of  splitting  open  the  distal  end  of  the  stump  of  the  tube  for 
some  little  distance  and  sewing  it  open,  and  then  establishing  the  patency  of 
the  tube,  if  practicable,  from  the  distal  end  to  the  uterine  cavity. 

9.  If  no  local  lesion  is  found,  improve  the  general  health  (by  the  use  of  ton- 
ics, and  exercise  and  other  appropriate  measures)  and  make  particular  inves- 
tigation as  to  the  husband's  condition.  In  regard  to  the  patient's  general 
health,  if  she  is  too  stout,  her  weight  should  be  reduced. 

10.  If  the  patient  has  been  taking  douches  for  the  treatment  of  any  disorder 
or  as  a  routine  measure,  stop  them.  In  cases  where  a  douche  is  really  neces- 
sary, direct  the  patient  to  employ  the  saline  douche,  and  to  postpone  its  use 
for  at  least  eighteen  hours  after  sexual  intercourse. 

LEUCORRHOEA. 

There  is  normally  a  slight  mueo-epithelial  discharge  about  the  genitals, 
sufficient  to  keep  the  parts  properly  moist.  Abnormal  discharge  may  be  only 
an  increase  in  the  normal  muco-epithelial  discharge,  or  the  discharge  may  be 
muco-purulent  in  character,  or  watery  or  bloody,  as  explained  on  page  32. 
For  convenience  the  various  kinds  and  discharge  may  be  grouped  under  the 
two  terms,  leucorrhoea  and  bloody  discharge.  These  disturbances  are  not 
diseases,  but,  like  the  other  disturbances  of  function,  are  only  symptoms. 

Under  the  term  ''leucorrhoea"  I  include  all  varieties  of  pathological  dis- 
charge from  the  genitals,  except  discharge  containing  blood. 

CAUSES  AND  DIAGNOSIS. 

Leucorrhoea  due  to  extra-genital  disturbances  only  and  without  local 
change  is  hardly  probable,  for  the  leucorrhoea  is  in  itself  evidence  of  some 
local  departure  from  the  normal  functional  activity.  Of  course,  there  are  in- 
stances, particularly  in  virgins,  in  which  the  functional  disturbance  evidenced 
by  the  leucorrhoea  is  dependent  largely  on  malnutrition  or  on  pelvic  con- 
gestion from  extra-genital  causes.  The  mild  leucorrhoea  found  in  anemic 
or  cachectic  patients  may  disappear  when  the  patient  is  put  in  good  general 
health.  Again,  in  pelvic  congestion  from  heart  disease,  or  from  some  general 
cause,  there  may  be  present  a  mild  leucorrhoea,  whicli  disappears  when  the 
functional  pelvic  congestion  is  corrected.  In  this  sense  leucorrhoea  may  be 
said,  in  some  cases,  to  be  due  to  extra-genital  causes  and  its  relief  to  depend 


LEUCORRHOEA  901 

upon  treatment  of  same.     In  all  but  these  exceptional  cases,  discharge  from 

the  genitals  is  due  to  oue  of  the  following  local  conditions: 

Inflammation  or  Ulcer  of  Vulva.  There  is  a  history  of  discharge  from 
the  vulva,  of  burning  or  itching,  and  of  frequent  urination,  with  perhaps  some 
pain.  Examination  of  the  external  genitals  shows  redness,  either  general 
or  localized  to  certain  areas.  There  is  tenderness  and  discharge,  and  also 
evidences  of  the  cause  of  the  intlammation  or  ulcer.  If  the  trouble  is  an 
ulcer,  it  may  be  simple,  chancroidal,  syphilitic,  tubercular  or  malignant.. 

Acute  Vaginitis.  There  is  a  history  of  a  free  yellow  discharge  of  short 
duration,  irritation  of  vulva  and  frequent  urination,  with  some  burning.  Ex- 
amination shows  a  yellowish  discharge  and  redness  of  vulva.  If  gonorrhoeal, 
there  is  usually  involvement  of  the  vulvovaginal  glands ;  also  the  discharge 
shows  gonococci.  The  vaginal  walls  are  rough  and  hot  and  tender — ^too  ten- 
der to  admit  of  satisfactory  bimanual  examination.  When  exposed  with  the 
speculum,  the  vaginal  walls  are  reddened  and  there  is  not  enough  discharge 
from  the  cervix  to  account  for  the  leucorrhoea. 

Chronic  Vaginitis.  This  occurs  principally  in  children.  There  has  been  a 
yellow  discharge  for  several  weeks  or  months,  with  irritation  of  the  vulva 
and  some  bladder  irritability.  Examination  shows  a  yellow  discharge  and 
redness  of  the  vulva,  with  more  or  less  tenderness.  The  discharge  should 
be  examined  for  gonococci.  If  the  patient  is  a  child,  no  vaginal  examination 
is  made.  If  an  adult,  examination  shows  tenderness  and  chronic  thickening 
and  roughness  of  vaginal  wall,  usually  most  marked  in  the  posterior  fornix. 
Speculum  examination  shows  redness  of  vaginal  wall,  either  general  or  in 
patches,  and  there  is  not  enough  discharge  from  the  cervix  to  account  for 
the  leucorrhoea. 

Adhesive  Vaginitis.  This  occurs  principally  near  or  after  the  menopause. 
There  is  a  history  of  chronic  discharge,  with  irritation  of  the  vulva,  and  some- 
times bladder  irritability.  On  examination  it  is  found  in  most  cases  that  the 
discharge  is  slight  and  is  sticky  or  "gluey"  in  character,  though  in  exceptional 
cases  it  is  free  and  purulent.  In  some  cases  there  are  scratch-marks,  result- 
ing from  the  patient's  attempts  to  overcome  the  pruritus.  On  vaginal  examina- 
tion the  vaginal  walls  are  found  adherent  in  spots,  especially  at  the  upper 
part  of  the  vagina.  If  the  adhesions  are  recent,  they  separate  easily,  with 
some  bleeding.  If  the  adhesions  are  old,  they  are  firm,  and  in  some  cases 
the  vagina  is  almost  obliterated  by  the  process.  "When  the  walls  are  separat- 
ed with  the  speculum,  in  the  less  advanced  cases,  irregular  spots  may  be  seen 
which  are  raw  and  bleed  slightly. 

Ulcer  of  Vagina.  This  may  be  simple,  chancroidal,  syphilitic,  tubercular, 
or  malignant.  There  is  a  history  of  an  acute  or  chronic  discharge  and  prob- 
ably also  of  other  evidences  of  the  disease  causing  the  ulceration.  Exam- 
ination shows  a  discharge  about  the  vulva  and  more  or  less  irritation  of  the 
surfaces.  When  making  the  vaginal  examination,  the  indurated  edges  or  base 
of  the  ulcer  may  be  felt.  The  speculum  exposes  the  ulcer  to  view,  and  further 
investigation  shows  it  to  be  the  sufficient  cause  of  the  discharge. 


902  DISTURBANCES  OF  FUNCTION 

Acute  Endocervicitis.  There  is  a  liistory  of  a  tenacious,  stringy  discharge 
of  recent  origin.  There  may  or  not  be  irritation  of  the  external  genitals. 
Vaginal  and  bimanual  examination  shows  nothing  special.  Speculum  exam- 
ination shows  a  stringy,  tenacious  discharge  coming  from  the  external  os. 
There  is  also  congestion  of  the  cervix  and  usually  erosion  about  the  external  os, 

Chronic  Endocervicitis.  There  has  been  a  discharge  for  a  long  time.  Vag- 
inal and  bimanual  examination  shows  no  e^ddence  of  involvement  of  the  cor- 
pus uteri  or  the  adnexa.  Specukun  examination  shows  a  very  tenacious, 
stringy,  mucopurulent  dicharge  from  the  external  os,  with  more  or  less  sur- 
rounding erosion.  In  many  cases  there  has  been  also  severe  laceration  of  the 
cer^dx,  the  evidences  of  wliicli  may  be  felt  and  seen. 

Laceration  of  Cervix.  In  these  cases  the  discharge  is  not  due  so  much 
to  the  tear  itself  as  to  the  subsequent  eversion,  and  irritation  and  chronic  in- 
flammation. The  various  appearances  presented  by  the  lacerated  cervix  are 
shown  in  Figs.  -iSl  to  4i2. 

Ulcer  of  Cervix.  Such  an  ulcer  may  be  simple,  chancroidal,  sjT)hilitic,  tu- 
bercular or  malignant.  There  is  a  liistory  of  leueorrhoea.  In  the  vaginal  ex- 
amination the  ulcer  of  the  cervix  may  or  may  not  be  felt,  depending  on  whether 
or  not  there  is  any  indiu'ation  in  the  edges  or  base.  VThen  the  cer^dx  is  ex- 
posed with  the  speculum,  the  ulcer  is  seen,  presenting  a  distinctly  marked 
margin  and  a  base  of  granulation  tissue. 

Malignant  Disease  of  Cervix.  This  may  appear  in  the  form  of  an  ulcer,  with 
indurated  margins  and  base,  or  as  a  papillary  growth  from  some  spot  on  the 
cervix  or  within  the  cervix.  For  the  various  appearances  of  beginning  ma- 
lignant disease  of  the  cervix  see  Figs.  443  to  447. 

Polypi  of  Cervix.  Polypi  of  the  cervix  of  various  kinds  may  give  rise  to 
considerable  leueorrhoea,  though  usually  a  bloody  discharge  is  the  promi- 
nent feature  in  these  cases  (page  562). 

Acute  endometritis,  whether  gonorrhoeal  or  due  to  pus  infection  following 
labor  or  miscarriage,  gives  rise  to  free  discharge.  There  is  a  history  of  recent 
labor  or  miscarriage,  or  instrumentation  or  gonorrhoea,  or  a  history  of  chronic 
endometritis  due  to  one  of  these  causes.  Examination  shows  a  free  discharge, 
the  character  of  which  points  to  the  cause  of  the  trouble,  as  explained  in 
chapter  VI.  Vaginal  and  bimanual  examination  show  tenderness  of  the  body 
of  the  uterus,  but  no  tenderness  around  the  uterus  unless  there  is  complicat- 
ing trouble.  Speculum  examination  shows  a  free  purulent  discharge  coming 
from  tlie  uterus. 

Chronic  Endometritis.  There  is  a  history  of  chronic  leueorrhoea.  Exam- 
ination shows  nothing  in  the  vagina  or  cervix  to  account  for  the  discharge. 
The  body  of  the  uterus  may  be  somewhat  enlarged  or  tender,  though  not  nec- 
essarily so.  Through  the  speculum  it  is  seen  that  the  discharge  comes  from 
the  uterus  and  not  from  inflammation  of  the  vaginal  wall.  The  character  of 
the  discharge  indicates  that  it  comes  largely  from  the  endometrium  and  not 
from  tlie  cervical  glands. 

Retrodisplacement  of  uterus  causes  leueorrhoea  by  causing  chronic  irrita- 
tion of  the  endometrium,  resulting  in  a  chronic  endometritis. 


LEUCORRHOEA  903 

Fibroid  of  uterus  causes  leucorrhoea  by  causing  chronic  irritation  of  the 
eudoiiK^triuin.  ])()tli  l)y  direct  pressure  and  by  interference  with  its  blood  supply. 

Cancer  of  corpus  uteri  causes  leucorrhoea  by  the  breaking  down  of  the  can- 
cerous area  and  also  hy  the  chronic  irritation  of  the  adjacent  endometrium. 

Periuterine  disease  causes  leucorrhoea  by  causing  chronic  congestion  of 
the  endometrium,  with  the  resulting  endometritis. 

Functional  congestion  of  the  uterus  or  pelvis  causes  leucorrhoea  by  the  nu- 
tritive and  so-ealh;Ml  inflammatory  changes  in  the  endometrium  and  cervical 
mucosa  resulting  therefrom. 

TREATMENT. 

For  the  purpose  of  considering  treatment,  it  is  convenient  to  divide  the  cases 
of  leucorrhoea  into  three  classes. 

1.  In  the  Virgin.  Leucorrhoea  is  not  an  infrequent  complaint  in  the  virgin. 
It  may  be  due  to  local  malnutrition  and  loss  of  tone  from  marked  anemia  (de- 
pendent on  chlorosis  or  other  cause),  it  may  be  due  to  pelvic  congestion  from 
obstruction  to  circulation  by  heart  disease  or  liver  disease,  or  other  extra-gen- 
ital affection,  or  it  may  be  due  to  functional  pelvic  congestion  incident  to  the. 
occupation  or  other  condition  mentioned  under  Menorrhagia  (page  864).  In 
the  virgin  it  is  assumed  that  the  leucorrhoea  is  due  to  one  of  these  causes,  un- 
less evidences  of  decided  local  disease  are  present,  and  treatment  is  given 
accordingly.     The  treatment  consists  of  the  following  measures : 

a.  The  administration  of  iron  and  other  tonics  internally  and  the  employ- 
ment of  the  other  measures  mentioned  in  the  tonic  regimen  for  the  treatment 
of  anemia  accompanying  amenorrheoa  (page  854). 

b.  The  use  of  laxatives  and  other  measures  required  to  overcome  any  chron- 
ic constipation  that  may  be  present. 

c.  The  administration  of  some  uterine  astringent  for  the  purpose  of  dim- 
inishing the  congestion  of  the  endometrium.  The  ergotin  capsule  (see  Form- 
ulae) is  a  very  good  preparation  for  that  purpose.  The  uterine  astringent  is 
specially  indicated  for  those  cases  accompanied  with  excessive  menstruation. 

d.  Where  the  discharge  persists  after  the  patient  has  been  put  in  good  gen- 
eral health  by  the  measures  mentioned  above,  a  vaginal  douche  may  be  order- 
ed to  be  taken  once  or  twice  daily.  It  is  well  to  start  with  a  mildly  astringent 
solution,  such  as  the  alum  douche  (one  teaspoonful  of  powdered  alum  to  tAvo 
quarts  of  hot  water)  or  the  aluminum  acetate  douche  (see  Formulae),  and  ad- 
vance to  the  stronger  astringents,  such  as  the  zinc  sulphate  and  the  alum 
douche  (see  Formulae),  if  necessary. 

e.  Local  examination,  with  such  subsequent  treatment  as  is  necessary  for 
the  particular  local  lesion  found.  In  the  virgin  this  is  reserved  for  those 
cases  in  Avhich  the  discharge  per.sists  after  the  employment  of  the  measures 
above  given  or  in  which  the  evidences  of  local  disease  are  so  marked  that  an 
examination  at  once  is  necessary. 

2.  With  Marked  Local  Lesion.  In  the  married  woman,  who  comes  com- 
plaining of  leucorrhoea,  an  examination  is  ordinarily  made  at  once  in  order 


904  DISTURBANCES  OF  FUNCTION 

to  determine  if  any  marked  lesion  is  present.  In  these  cases,  and  also  in  ex- 
ceptional cases  of  the  previous  class  in  which  an  examination  is  finally  nec- 
essary, it  may  be  found  that  there  is  a  decided  local  lesion,  or  that,  on  the 
other  hand,  the  parts  show  no  decided  lesion. 

When  a  marked  lesion  that  constitutes  sufficient  cause  for  the  leucorrhoea 
is  present,  it  should,  of  course,  receive  the  appropriate  treatment.  The  va- 
rious lesions  that  may  cause  a  discharge  from  the  genitals  have  just  been  men- 
tioned in  the  preceding  pages,  and  the  treatment  required  for  each  lesion  is 
detailed  in  the  chapter  dealing  with  such  lesion.  In  many  of  these  cases  the 
leucorrhoea  is  a  very  subordinate  feature,  the  treatment  being  principally  for 
the  relief  of  more  serious  symptoms.  In  the  case  of  many  patients  with  a 
chronic  uterine  discharge,  in  which  there  is  a  more  serious  disorder  requiring 
some  operative  procedure,  it  is  well  to  curet  the  interior  of  the  uterus  at  the 
same  time  in  order  to  check  the  discharge. 

3.  Without  Marked  Lesion.  In  some  patients  with  troublesome  leucorrhoea 
the  examination  shows  no  marked  lesion.  There  is  probably  a  mild  chronic 
endometritis  or  hyperplasia  of  the  endometrium,  but  there  is  nothing  that 
gives  rise  to  any  symptoms  other  than  the  leucorrhoea,  with  perhaps  a  slight 
tendency  to  excessive  menstrual  flow. 

In  such  a  case  employ  the  measures  just  mentioned  for  treatment  in  the 
virgin.  If  these  do  not  suffice,  then  a  few  astringent  intra-uterine  applica- 
tions (see  page  321)  may  be  made  if  the  cervix  dilates  easily,  or  a  few  intra- 
uterine applications  of  electricity.  If  the  leucorrhoea  still  persists  to  a 
troublesome  extent,  thorough  curetment  of  the  interior  of  the  uterus  under 
anesthesia  should  be  employed.  The  curetment  should  be  followed  by  a 
general  and  local  tonic  regimen,  that  the  new  endometrium  may  develop  under 
bettered  conditions. 

In  suspicious  cases  of  persistent  uterine  discharge,  the  material  removed  in 
the  curetment  should  be  submitted  to  microscopic  examination,  that  the  pres- 
ence or  absence  of  malignant  disease  of  the  endometrium  may  be  positively 
determined. 

BLOODY  DISCHARGE. 

Bleeding  not  connected  with  menstruation  may  vary  from  a  streak  of 
blood,  or  a  slight  coloring  of  a  muco-purulent  discharge,  to  a  free  flow  of 
blood.  Occasionally  there  is  a  hemorrhage  sufficiently  free  to  threaten  the 
patient's  life.  In  most  cases,  however,  the  bloody  discharge  is  slight  and 
irregular,  and  is  of  serious  import  only  because  it  may  have  a  serious 
condition  for  its  cause. 

CAUSES. 

Any  of  the  following  disorders  may  cause  a  bloody  discharge  from-  the 
genitals,  the  character  of  the  discharge  varying  from  a  muco-purulent  dis- 
charge, only  streaked  with  blood,  to  a  profuse  flow  of  blood  and  clots.     All  of 


BLOODY  DISCHARGE  905 

the  eonditions  mentioned  in  the  first  part  of  the  list  give  rise,  also,  to  leucor- 
rhoea  and  are  mentioned  under  it.  The  other  conditions  occur  with  preg- 
nancy and  must  be  thought  of  whenever  a  bloody  discharge  is  complained  of : 

Inflammation  or  Ulcer  of  Vulva. 

Acute  Vaginitis, 

Chronic  Vaginitis. 

Adhesive  Vaginitis. 

Ulcer  of  Vagina. 

Acute  Endocervicitis. 

Chronic  Endocervicitis. 

Laceration  of  Cervix. 

Ulcer  of  Cervix. 

Cancer  of  Cervix. 

Polypi  of  Cervix. 

Acute  Endometritis. 

Chronic  Endometritis. 

Retrodisplacement  of  Uterus. 

Fibroid  of  Uterus. 

Cancer  of  Corpus  Uteri. 

Periuterine  Disease. 

Functional  Congestion. 

Threatened  Miscarriage.  The  patient  may  have  missed  the  menses  only  a 
few  days  or  may  be  several  months  pregnant.  Threatened  miscarriage  is 
usually  accompanied  by  considerable  pelvic  pain.  In  exceptional  cases  there 
may  be  a  bloody  discharge  for  several  hours,  or  a  day  or  two,  before  pains 
begin.  In  some  cases,  by  questioning  the  patient,  it  will  be  found  that,  fail- 
ing to  come  unwell  at  the  proper  time,  she  has  been  taking  medicine  to  pro- 
duce an  abortion  ("to  bring  on  the  flow"). 

Miscarriage.  Here  there  are  sharp,  cramp-like  pains,  with  the  expulsion  of 
blood-clots  and  pieces  of  membrane  or  a  formed  fetus,  depending  on  the 
period  of  pregnancy  at  which  the  accident  happens.  Then  the  pain  subsides 
and  after  a  few  days  the  bloody  discharge  ceases. 

Incomplete  Miscarriage.  The  uterus  is  not  entirely  emptied  and  the 
retained  remnants  cause  a  persistent  bloody  discharge  for  one  or  two  weeks 
after  it  should  have  stopped,  and  there  is  resulting  subinvolution  of  the 
uterus.  The  blood  may  pass  as  a  muco-sanguinous  discharge  or  in  clots. 
It  may  disappear  when  the  patient  stays  in  bed,  to  reappear  when  she  gets 
up.  This  is  perhaps  the  most  frequent  cause  of  persistent  bleeding  in  women 
of  the  child-bearing  age.  There  is  usually  little  pain  after  the  miscarriage 
has  taken  place.  The  principal  symptom  is  the  bleeding,  with  the  resulting 
anemia  and  weakness.  If  infection  takes  place,  the  symptoms  of  sepsis  are 
added. 

Placenta  Praevia.  Bleeding  from  this  cause  does  not  usually  take  place 
until  the  pregnancy  lias  advanced  so  far  that  the  diagnosis  is  perfectly  clear. 

Laceration  of  Cervix  with  Pregnancy.    The    cervix    is  lacerated,  everted 


906  DISTURBANCES  OF  FUNCTION 

and  eroded,  and  there  is  added  the  softening  and  congestion  from  pregnancy. 
There  are  no  pains  such  as  accompany  miscarriage.  There  may  be  some 
slight  pain  and  uneasiness  in  pelvis,  which  is  relieved  by  lying  down.  The 
bloody  discharge  persists,  off  and  on,  without  apparent  evidence  of  threat- 
ened miscarriage  or  other  intra-uterine  disturbance. 

Tubal  Pregnancy.  The  rupture  of  a  tubal  pregnancy,  or  a  tubal  abor- 
tion, is  nearly  always  followed  in  a  few  days  by  an  irregular  bloody  dis- 
charge, which  may  persist  for  several  days  or  several  weeks.  In  some  cases 
pieces  of  membrane  are  associated  with  the  bloody  discharge.  There  are 
also  the  other  evidences  of  tubal  pregnancy  (page  773). 

Myopathica  Hemorrhagica.  This  is  a  symptomatic  term  used  to  designate 
the  condition  in  certain  uteri  that  bleed  persistently  in  spite  of  repeated 
curettage,  without  sufficient  reason  so  far  as  any  gross  lesion  is  concerned.  On 
microscopic  examination  of  such  uteri,  practically  all  are  found  to  have 
have  marked  disease  of  the  vessel  walls — in  some  instances  local,  in  others 
general. 

TREATMENT. 

In  considering  the  treatment  of  bloody  discharge  from  the  genital  tract,  it 
is  well  to  divide  the  cases  into  two  classes — those  with  an  evident  local  lesion 
and  those  without  evident  lesion. 

1.  With  Marked  Local  Lesion.  In  a  certain  proportion  of  the  cases  in  which 
the  patient  comes  complaining  of  a  bloody  discharge,  the  ordinary  gynecologic 
examination  will  show  a  marked  lesion  of  the  external  genitals,  or  the  vagina 
or  the  uterus,  of  such  nature  as  to  account  for  the  bloody  discharge.  The 
treatment  required  is  the  regular  treatment  for  the  particular  lesion,  the 
details  of  which  are  given  in  the  appropriate  chapter. 

When  there  is  free  hemorrhage  from  the  uterus,  a  firm  vaginal  packing 
or  tamponade  may  be  used  for  temporary  effect.  This  is  best  applied  with 
the  patient  in  the  Sims  posture  and  the  perineum  retracted  with  the  Sims 
speculum.  The  gauze  or  cotton  used  for  the  packing  should  first  be  dipped 
in  an  antiseptic  solution  and  then  squeezed  as  dry  as  possible.  Gauze  or 
cotton  thus  prepared  is  much  more  effective  for  checking  hemorrhage  than 
when  perfectly  dry.  No  firm  vaginal  packing  should  be  employed  in  a  preg- 
nant patient  as  long  as  there  is  a  chance  of  preserving  the  pregnancy,  as 
such  a  packing  might  cause  a  miscarriage. 

2.  Without  Marked  Local  Lesion.  The  ordinary  gynecologic  examination 
shows  no  decided  lesion.  It  is  evident  that  the  bloody  discharge  comes  from 
within  the  uterus,  but  the  history  and  examination  show  no  other  sign  of 
uterine  disease,  except  perhaps  some  menstrual  disturbance.  What  is  to  be 
done  for  such  a  patient? 

The  following  treatment  should  be  employed : 

a.  Tonics.  It  is  important  to  overcome  any  marked  anemia  or  general 
malnutrition  by  the  administration  of  iron  and  other  internal  remedies  as 


BLOODY  DISCHARGE  907 

indicated  and  the  employment  of  the  other  measures  of  an  effective  tonic 
regimen. 

b.  Laxatives.  The  careful  regulation  of  the  bowels  is  needed,  both  for 
the  local  effect  in  diminishing  pelvic  congestion  and  for  the  general  effect  in 
improving  nutrition. 

c.  Uterine  Astringents.  Ergotin  or  stypticin  should  be  given  regularly, 
three  to  four  times  daily,  for  a  period  of  two  or  three  weeks  in  order  to 
secure  the  full  hemostatic  effect.  This  is  to  some  extent  a  diagnostic  meas- 
ure as  well  as  a  therapeutic  measure.  If  the  bloody  discharge  is  due  simply 
to  subinvolution  or  a  mild  endometritis,  it  is  likely  to  cease  under  these  meas- 
ures and  remain  away  permanently  if  the  treatment  is  continued  for  some 
months — long  enough  to  restore  the  general  health  and  the  local  tone.  If 
the  bloody  discharge  persist  in  spite  of  above  measures  continued  for  a  few 
weeks,  it  means  that  there  is  some  decided  change  in  the  endometrium.  This 
may  be  only  chronic  inflammation  or  it  may,  on  the  other  hand,  be  beginning 
malignant  disease.  In  such  a  case  the  interior  of  the  uterus  should  be  thor- 
oughly curetted  under  anesthesia  and  the  curettings  submitted  to  microscopic 
examination.  If  the  trouble  is  inflammatory,  this  is  the  most  effective  thera- 
peutic measure.  If  the  trouble  is  malignant,  the  diagnosis  is  thus  made  early, 
at  a  time  when  removal  of  the  uterus  will  probably  effect  a  cure. 

d.  Vaginal  Douches.  Douches  are  usually  given  along  with  the  three 
measures  previously  mentioned.  If  there  is  a  purulent  discharge,  a  strong 
antiseptic  is  used — for  example,  the  bichloride  douche.  If  there  is  no  decided 
purulent  discharge,  an  astringent  is  used,  such  as  alum,  or  zinc  sulphate  and 
alum  (see  Formulae). 

e.  Intra-uterine  Applications.  In  some  cases  a  few  intra-uterine  applica- 
tions may  be  made  for  therapeutic  and  diagnostic  effect.  Copper  sulphate 
(10%  solution)  is  the  preferable  astringent  to  use.  In  simple  hyperplasia 
or  mild  inflammation  it  tends  to  stop  the  bleeding.  In  beginning  malignant 
disease  the  bloody  discharge  persists. 

f.  Curetment.  When  there  is  a  bloody  discharge  that  persists  off  and  on, 
in  spite  of  other  measures  employed  for  a  few  weeks,  then  thorough  curet- 
ment  under  anesthesia  is  indicated  as  a  diagnostic  and  therapeutic  measure. 
In  cases  where  the  cervical  canal  is  wide,  or  where  it  dilates  easily  without 
much  pain,  some  scrapings  from  the  endometrium  may  be  obtained  in  the 
regular  office  examination  by  means  of  the  small  exploring  curet  (Fig.  101). 
If  such  scrapings  show  malignant  disease,  the  diagnosis  is  thus  established 
without  anesthesia.  If  the  scrapings  do  not  show  malignant  disease,  then 
curetment  under  anesthesia  is  indicated,  for  in  such  a  case  malignant  disease 
cannot  be  excluded  until  a  thorough  curetment  is  made  and  all  the  scrapings 
examined.  If  no  malignant  disease  is  found,  but  the  bleeding  recurs,  a  second 
curetment  with  examination  of  the  scrapings  is  indicated.  If  the  bleeding 
recurs  only  at  long  intervals,  repeated  curettage  may  be  employed  with  much 
benefit,  provided  malignancy  can  be  positively  excluded. 

g.  Hysterectomy.   If  malignant  disease  is  present,  hysterectomy  at  once  is, 


908  DISTURBANCES  OF  FUNCTION 

of  course,  indicated.  If  no  malignant  disease  is  present,  but  still  the  bleeding 
recurs  soon  after  curetment,  and  especially  after  repeated  curetment,  hyster- 
ectomy may  be  necessary.  It  is  clearly  indicated  where  the  uterine  wall  is 
damaged  permanently  and  to  a  serious  extent,  by  scattered  fibroid  nodules, 
by  chronic  metritis  (sclerosis)  or  by  the  condition  designated  as  "myopathica 
hemorrhagica." 


909 


CHAPTER  XV. 

INVASION  OF  THE  PERITONEAL  CAVITY 

For  the  Treatment  of  Gynecologic  Diseases. 

In  the  treatment  of  certain  gynecologic  affections  it  is  necessary  to  invade 
the  peritoneal  cavity.  This  invasion  of  the  great  peritoneal  sac  in  the  center 
of  the  body  necessarily  carries  with  it  much  risk  to  the  patient.  In  the  pre- 
antiseptic  days  the  mortality  was  great — so  great  that  the  operation  was 
but  rarely  resorted  to.  By  modern  antiseptic  and  aseptic  methods,  however, 
the  mortality  has  been  reduced  to  a  very  small  per  cent.  But  though  the 
mortality  of  the  operation  is  small,  we  must  not  forget  that  there  is  a  mor- 
tality due  directly  to  the  operation. 

The  danger  varies  much  in  different  cases,  depending  on  the  particular 
form  of  disease  present  and  on  the  condition  of  the  patient  at  the  time  of 
operation — but  there  is  some  danger  in  every  case.  I  call  particular  atten- 
tion to  this  because  some  physicians  seem  prone  to  overlook,  or  at  least  fail 
to  give  proper  weight  to,  the  fact  that  occasionally  a  patient,  with  everything 
apparently  favorable,  will  die,  and  no  one  can  promise  any  patient  abso- 
lutely that  she  will  survive.  One  may  say,  in  a  favorable  case,  that  the  risk 
is  very  slight  and  that  in  all  probability  the  patient  will  go  through  the 
operation  and  convalescence  without  trouble.  But  though  the  risk  is  slight, 
it  is  nevertheless  a  risk,  and  the  patient  or  her  friends  must  so  understand 
it.  Such  necessary  explanation  to  the  patient  or  her  relatives  is  made  with 
much  better  grace  before  operation  than  afterward. 

The  peritoneal  cavity  may  be  readily  entered  in  two  ways — by  incision 
through  the  anterior  abdominal  wall  (abdominal  section)  or  by  incision 
through  the  vaginal  wall  (vaginal  section). 

ABDOMINAL  SECTION. 

Abdominal  section  is  incision  into  the  peritoneal  cavity  through  the  ab- 
dominal wall.  This  is  known  also  as  "celiotomy"  and  as  "laparotomy," 
and  as  "suprapubic  section."  These  terms  all  refer  simply  to  the  incision 
through  the  abdominal  wall  into  the  peritoneal  cavity  and  not  to  the  subse« 
quent  operative  manipulations  carried  out  within  the  cavity. 

The  incision  may  be  located  at  any  part  of  the  wall — in  the  median  lino  or 
laterally.  The  direction  of  the  incision  may  be  longitudinal  or  transverse  or 
oblique,  or  a  combination  of  these  directions. 

There  is  usually  some  additional  operative  procedure  carried  out  after  the 
peritoneal  cavity  is  opened,  and  this  additional  procedure  frequently  gives 


910  INVASION  OF  THE  PERITONEAL  CAVITY 

the  name  to  the  whole  operation — for  example,  ovariotomy  (abdominal  sec- 
tion with  removal  of  an  ovary  or  an  ovarian  tumor),  myomectomy  (abdomi- 
nal section  with  removal  of  a  fibromyoma  of  the  uterus),  abdominal  hysterec- 
tomy (abdominal  section  with  removal  of  the  uterus). 

INDICATIONS 

For  Abdominal  Section. 

The  most  common  indications  for  abdominal  section  in  gynecologic  work 
are  as  follows : 

1.  Ovarian  tumors. 

2.  Broad  ligament  tumors. 

3.  Uterine    fibromyomata   with    serious    symptoms    not   yielding   to 

minor  measures.  The  abdominal  operations  in  these  cases  are 
myomectomy,  supravaginal  hysterectomy,  and  total  abdominal 
hysterectomy. 

4.  Cancer  of  the  uterus  (total  abdominal  hysterectomy). 

5.  Extra-uterine  pregnancy. 

6.  Acute  pelvic  inflammation  which  spreads  in  spite  of  other  meas- 

ures and  threatens  life. 

7.  Chronic  pelvic  inflammation  with  a  collection  of  pus  high  in  the 

pelvis,  as  in  pyosalpinx. 

8.  Chronic  pelvic  inflammation  with  a  large  amount  of  exudate  and 

persistent  troublesome  symptoms. 

9.  Chronic  pelvic  inflammation  without   decided   exudate,  if  every- 

thing else  fails  to  relieve  the  pelvic  distress. 

10.  Pelvic  tuberculosis,  if  other  measures  fail  to  produce  decided  im- 

provement. 

11.  Adherent    retrodisplacement    of  uterus     or    persistent     prolapse, 

causing  troublesome  symptoms  and  not  yielding  to  less  danger- 
ous measures. 

12.  Obscure  or  doubtful  pelvic  disease  which,  in  spite  of  other  meas- 

ures, threatens  the  patient  with  death  or  with  chronic  invalidism 
(exploratory  abdominal  section). 

CONTRA-INDICATIONS. 

The  more  common  contra-indications  to  abdominal  section  are : 

1.  Marked  nephritis,  especially  chronic  interstitial  nephritis. 

2.  Diabetes  mellitus. 

3.  Inoperable  cancer  or  advanced  pulmonary  tuberculosis. 

4.  Any  chronic  disease,  general  or  local,  causing  marked  weakness 

and  lessening  the  patient's  resistance. 

5.  Acute  disease  that  may  be  aggravated  by  the  operation. 

6.  Dermatitis  within  the  operative  field. 

All  these  contra-indications  are  of  course  only  relative.    There  may  arise 


ABDOMINAL  SECTION  911 

circumstances  demanding  the  operation  at  once  in  spite  of  contra-indica- 
tions — that  is,  circumstances  in  which  the  danger  of  delay  would  be  greater 
than  the  danger  of  immediate  operation.  But  when  the  case  is  not  one  of 
extreme  urgency,  the  operation  should  be  postponed  until  the  complicating 
condition  can  be  corrected  and  the  patient  placed  in  better  condition. 

Pregnancy  increases  the  danger  of  abdominal  section  very  decidedly,  l)ut 
it  is  not  often  a  contra-indication  for  the  reason  that  the  disease  requiring 
operation  (for  example,  a  large  tumor  or  an  abscess)  precludes  the  full  de- 
velopment of  the  fetus  or  makes  the  dangers  from  advancing  pregnancy 
greater  than  those  from  immediate  operation. 

DANGERS 

Of  Abdominal  Section. 

The  immediate  dangers  of  an  abdominal  section  are  three : 

1.  Failure  of  the  vital  forces  to  stand  the  shock  of  the  operation.  This 
shock  is  due  principally  to  (a)  the  loss  of  blood,  (b)  the  handling  of  intra- 
peritoneal structures  and  (c)  the  anesthesia. 

2.  Failure  of  the  vital  organs  (heart,  lungs,  kidneys  and  gastro-intestinal 
tract)  to  perform  the  extra  work  thrown  on  them  in  the  first  few  days  fol- 
lowing the  operation. 

3.  The  development  of  infection,  causing  general  peritonitis  or  localized 
suppuration. 

PREPARATIONS 

For  Abdominal  Section. 

In  order  to  reduce  to  a  minimum  the  dangers  of  the  operation,  careful 
preparation  is  required. 

The  operation  should,  when  possible,  be  carried  out  in  the  clean,  well- 
arranged  operating  room  of  a  hospital,  even  though  the  patient  has  to  be 
moved  a  considerable  distance  to  obtain  the  requisite  hospital  facilities.  Ab- 
dominal section  is  too  serious  an  operation  to  be  undertaken  in  the  home 
if  the  patient's  condition  will  permit  her  removal  to  a  hospital. 

When  the  operation  must  be  performed  at  the  home  of  the  patient,  the 
room  should  be  made  as  clean  and  free  from  dust  as  possible  by  the  follow- 
ing steps : 

a.  One  or  two  days  before  operation  remove  the  bric-a-brac  and  super- 
fluous furniture  and  sweep  the  walls,  ceiling  and  floor  thoroughly. 

b.  The  carpet  may  be  removed,  leaving  the  bare  floor,  or,  after  sweeping 
the  carpet  well,  it  may  be  covered  completely  with  oilcloth  well  tacked 
down. 

c.  All  the  wood-work  should  then  be  thoroughly  scrubbed  with  soap  and 
water  and  afterward  with  an  antiseptic  solution. 

The  further  preparations  for  the  operation  may  be  divided  into  three  parts 
as  follows: 


912  INVASION  OF  THE^PERITONEAL  CAVITY 

A.  Preparation  of  the  patient. 

B.  Preparation  of  instruments  and  dressings. 

C.  Preparation  of  operator  and  assistants. 

A.  Preparation  of  the  Patient.  The  patient,  having  been  subjected  to  a 
careful  general  examination,  including  urine  analysis,  to  exclude  contra-indica- 
tions,  is  sent  to  the  hospital  one  or  two  days  before  operation,  that  the  proper 
preparation  may  be  carried  out.  Of  course  there  are  cases  of  rapidly  spread- 
ing pehdc  inflammation,  or  of  intra-abdominal  hemorrhage  or  injury,  in  which 
the  abdomen  must  be  opened  at  the  earliest  possible  moment.  In  such  a  case 
there  is  no  time  for  preliminary  preparation — careful  immediate  sterilization 
is  carried  out  and  the  abdomen  is  then  opened.  But  when  the  case  is  not  an 
emergency  one,  the  preliminary  preparation  should  be  made.  It  gives  the 
patient  a  decidedly  better  chance  of  complete  and  uninterrupted  recovery. 

The  purposes  of  this  preliminary  ]3reparation  are : 

a.  To  tone  up  the  patient's  nervous  system  so  that  she  will  be  better 

able  to  stand  the  operation. 

b.  To  see  that  the  kidneys  are  in  good  working  order,  and  to  prepare 

the  urine  for  possible  catheterization. 

c.  To  nourish  the  patient  so  as  to  limit  intestinal  decomposition,  and 

to  empty  the  intestine  tract  well  just  before  operation. 

d.  To  prepare  a  sterile  field  for  the  operative  work. 

These  desired  results  are  secured  by  a  program  ordinarily  about  as  follows, 
supposing  the  time  for  operation  to  be  an  early  morning  hour : 

1.  Nervous  System  and  General  Measures.  For  two  or  three  days  before 
operation  the  patient  is  given  strychnia  sulphate  1-40  gr.  by  mouth  every  four 
to  eight  hours,  depending  upon  the  amount  of  stimulation  needed.  If  the 
patient's  stomach  is  much  disturbed,  tliis  may  be  given  hypo  dermatic  ally. 
Such  other  medicines  should  be  given  as  are  indicated  by  pain  or  nausea,  or 
cough  or  other  symptoms.  If  there  is  a  vaginal  discharge,  give  an  antiseptic 
douche  once  or  twice  daily. 

2.  Kidneys  and  Urine.  Determine  whether  the  kidneys  are  doing  their 
work  well.  ]\rake  the  regular  analysis  of  the  urine,  and,  when  indicated,  the 
special  examinations.  As  the  patient  may  have  to  be  catheterized  after  opera- 
tion, it  is  well  to  give  some  urinary  antiseptic  for  a  day  or  two  before — such, 
for  example,  as  urotropin,  5  grains  in  glass  of  water  every  eight  hours.  Have 
the  patient  take  water  rather  freely. 

Formerly  I  took  particular  pains  to  thoroughly  saturate  the  patient  with 
water  before  operation,  for  the  purpose  of  aiding  the  kidney  action  after 
operation  and  diminishnig  the  thirst,  but  have  discontinued  tlie  practice  as  a 
routine  because  I  found  certain  drawbacks — the  principal  one  being  that  it 
interfered  with  spontaneous  urination  after  operation.  The  avoidance  of 
catheterization  is  much  to  be  desired  and  can  usually  be  accomplished,  pro- 
vided the  bladder  does  not  fill  until  the  patient  has  well  recovered  from  the 
anesthesia.  In  the  watei*  saturated  patients  the  urine  is  secreted  so  rapidly 
that  frequently  the  bladder  becomes  distended  before  the  reflexes  are  suffi- 


PREPARATIONS  FOR  ABDOMINAL  SECTION  913 

ciently  established  to  bring  about  spontaneous  urination.     In  certain  eases, 
however,  wliere  the  kidneys  are  defective,  I  still  employ  it. 

3.  Diet  and  Laxatives.  Light  diet  is  to  be  given  up  to  and  including  noon 
of  the  day  before  operation,  then  liquids  only,  but  with  water  in  abundance. 
After  midnight,  just  preceding  the  operation,  nothing  is  to  be  given  by  mouth 
but  water — the  water  may  be  continued  up  to  within  an  hour  of  the  operation. 
A  dose  of  castor  oil  (1  to  2  ounces)  is  to  be  given  about  3  P.  M.  the  day  before 
operation,  and  the  next  morning  an  enema  until  the  water  returns  clear. 

The  idea  is  to  have  the  intestinal  tract  in  as  near  a  normal  condition  as 
possible  (hence  no  abnormal  putrefaction),  with  simply  a  good  clearing  out 
by  a  non-irritating  purgative  just  before  the  operation.  Experience  has 
shown  that  this  simple  method  of  preparation  brings  the  patient  to  the  operat- 
ing table  in  better  condition  and  causes  less  disturbance  after  the  operation 
than  the  prolonged  dieting  and  purging  formerly  employed.  The  latter  upset 
the  functional  routine  of  the  intestine,  disturbed  the  normal  peristalsis, 
increased  the  intestinal  irritation  and  putrefaction,  and  reduced  the  patient's 
strength. 

When  there  are  complications  that  may  necessitate  resection  of  the  intestine  • 
or  opening  of  the  stomach,  then,  of  course,  the  usual  preoperative  measures 
for  approximate  sterilization  of  the  upper  intestinal  tract  should  be  employed. 

4.  Sterilization  of  the  Field.  Five  to  fifteen  hours  before  operation  (most 
conveniently  the  afternoon  or  evening  before)  cover  the  whole  abdomen  with 
a  poultice  composed  of  absorbent  cotton  soaked  in  a  solution  of  green  soap  in 
warm  water.  The  cotton  should  be  applied  sufficiently  wet  so  that  the  skill 
■\^^11  be  thoroughly  soaked  by  the  soapy  water.  This  loosens  all  the  dead 
epidermal  scales  and  all  extraneous  particles  on  the  skin  and  makes  the  sub- 
sequent shaving  much  more  effective  as  a  cleansing  process.  After  the  soap 
solution  has  been  on  half  an  hour  to  an  hour,  remove  it  and  shave  the  abdomen. 
Then  scrub  the  abdomen  well  with  absorbent  cotton  or  a  very  soft  brush, 
using  warm  water  and  green  soap  or  ethereal  soap.  At  this  point  your  hands 
should  be  again  sterilized.  Then  wash  off  the  soap  solution  vrith  sterile  water. 
Then  wash  the  abdomen  carefully  and  vigorously  with  alcohol  (about  80%), 
using  sterile  cotton  balls.  Then  wash  with  bichloride  solution  (1-2000),  using 
sterile  cotton  balls.  Then  apply  a  compress  of  absorbent  cotton  moistened 
with  bichloride  solution  (1-5000).  This  compress  is  to  remain  in  place  until 
after  the  patient  is  under  the  anesthetic,  or,  if  preferred,  the  bichloride  dress- 
ing may  be  removed  a  short  time  before  anesthesia  and  the  cleansing  process 
repeated.  In  this  process  of  sterilization  special  attention  must  be  given  to  the 
umbilical  depression  and  other  irregularities  in  the  surface.  When  the  patient 
is  on  the  operating  table  and  under  the  anesthetic,  the  bichloride  compress  is 
removed  and  the  field  again  washed  with  alcohol  or  ether,  applied  by  means 
of  cotton  balls,  then  M^th  sterile  water  applied  in  the  same  way.  The  abdomen 
is  then  dried  with  sterile  gauze  and  is  ready  for  incision.  If  the  vagina  also 
is  to  be  invaded  during  the  operation,  it  must  be  prepared  as  described  later 
under  vaginal  section. 


914  INVASION  OF  THE  PERITONEAL  CAVITY 

There  are  many  minor  variations  from  the  above  used  in  different  hospitals, 
to  some  of  vhich  variations  much  importance  is  attached  by  those  using  them. 
I  have  been  on  the  lookout  for  improvements,  but  so  far  have  encountered 
nothing  that,  on  critical  analysis,  surpasses  this  standard  method  in  simplicity 
and  effectiveness.  In  hurry  cases,  where  the  abdomen  must  be  opened  at  the 
earliest  possible  moment,  the  preliminary  softening  and  loosening  of  the  epi- 
dermal scales  by  the  soap  poultice  must  be  dispensed  with,  and  consequently 
extra  care  must  be  exercised  in  the  other  steps  of  the  preparation.  Here 
Harrington's  solution  (corrosiv.  sublimate,  0.8  gm. ;  water,  300  c.c. ;  hydro- 
chloric acid,  60  c.c:  alcohol,  640  c.c.)  is  preferable  to  the  plain  bichloride 
solution.  It  is  a  much  stronger  disinfectant,  but  more  irritating.  The  various 
"rapid"  methods  of  abdominal  disinfection  should,  it  seems  to  me,  be  confined 
to  emergency  cases,  in  which  there  is  not  time  for  the  regular  and  more  reliable 
process  of  skin  cleansing. 

B.  Preparation  of  Instruments  and  Dressings.  There  are  several  ways  of 
preparing  instruments,  sutures,  dressings,  etc. 

The  usual  method  is  as  follows : 

1.  Instruments  are  boiled  ten  to  fifteen  minutes.  They  must  be  entirely 
immersed  in  the  water  and  the  water  must  boil  (not  simply  simmer)  for  at 
least  ten  minutes.  A  1%  solution  of  sodium  carbonate  (washing  soda)  is  pre- 
ferable to  plain  water,  as  it  tends  to  prevent  rusting  of  instruments.  There 
are  a  few  exceptions  to  the  boiling  rule.  The  knives  and  scissors  are  usually 
soaked  in  95%  carbolic  acid  for  ten  minutes  or  in  10%  carbolic  solution  for 
half  an  hour,  as  boiling  tends  to  dull  them.  However,  if  in  a  hurry,  they 
may  be  boiled  with  the  other  instruments,  in  which  case  the  cutting  edge 
should  be  wrapped  in  cotton. 

2.  Gauze  sponges  and  pads  and  dressings  are  sterilized  in  the  steam  sterilizer. 
The  goAvns  for  operator  and  assistants,  and  the  sterile  cloths  and  sheets,  and . 
instrument -trays  and  basins  are  put  through  the  same  process. 

In  emergency  work  in  the  country,  where  no  steam  sterilizer  is  available,  an 
ordinary  wash  boiler  may  be  used.  The  various  articles  to  be  sterilized  (gauze, 
sponges,  towels,  sheets,  gowns,  etc.)  are  wrapped  in  small  packages,  each 
package  being  wrapped  in  two  thicknesses  of  cloth,  and  are  then  boiled  for 
thirty  minutes.  In  order  to  dry  the  gowns  somewhat,  they  may  be  removed 
from  the  boiler,  wrung  as  dry  as  pos.sible  Avith  clean  hands,  being  careful 
to  not  disturb  the  double  covering,  and  then  dried  in  an  oven. 

In  regard  to  the  form  of  sponges  used,  I  would  strongly  recommend  the 
gauze-strip  sponges  for  abdominal  work  (page  925).  The  numerous  detached 
sponges  ordinarily  used  are  dangerous  and  have  led  to  many  deplorable 
accidents. 

3.  As  to  suture  and  ligature  materials,  silk  and  silkworm  gut  are  boiled 
along  with  the  instruments.  Reliable  catgut  may  be  purchased,  sterilized 
and  ready  for  use. 

4.  The  rubber  gloves  are  wrapped  in  a  towel  and  boiled  along  with  the 
instruments.     After   boiling  they   are   placed  in   1-5000   bichloride   solution. 


PREPARATIONS   FOR   ABDOMINAL  SECTION  915 

They  are  much  easier  put  on  when  partly  filled  with  solution.  The  weak 
bichloride  solution  is  used,  so  as  to  kill  any  bacteria  that  may  work  to  the 
surface  of  the  skin  of  the  hands  during  the  course  of  the  operation.  When 
the  gloves  are  put  on  in  simply  sterile  w^ater,  the  warm  mixture  of  sterile 
water  and  macerated  epithelium,  which  forms  in  the  glove  during  the  course 
of  a  long  operation,  becomes  a  culture-medium  for  the  bacteria  which  w^ork 
to  the  surface  from  the  deeper  layers  of  the  skin,  and  which  may  be  liberated 
in  the  peritoneal  cavity  by  a  puncture  of  the  glove. 

C.  Preparation  of  Operator  and  Assistants.  Everything  that  is  to  come  in 
contact  with  the  operative  field  must  be  sterilized.  The  hands  and  forearms 
of  the  operator  and  assistants  must  be  disinfected  as  far  as  possible,  and  should 
then  be  covered,  so  that  there  is  no  chance  of  direct  contact  of  the  operative 
field  with  the  skin  of  the  hands  or  arms,  for  the  skin  can  not  be  absolutely 
sterilized.  Again,  the  operator  and  assistants  must  be  so  covered  as  to  effect- 
ually protect  the  field  of  operation  from  contamination  by  the  clothing  or  by 
particles  from  the  hair  or  beard,  or  by  particles  carried  in  the  breath. 

The  accomplishment  of  this  thorough  protection  of  the  operative  wound 
has  been  the  object  of  many  decades  of  study  and  experimentation.  The 
present  effective  technique  for  the  preparation  of  the  operator,  as  well  as  all 
the  other  antiseptic  and  aseptic  preparations,  w^as  attained  gradually  by  im- 
provements added  year  by  year,  but  it  is  all  the  direct  outgrowth  of  the 
epoch-making  work  of  Pasteur  and  of  Lister.  The  following  are  the  steps 
in  the  preparation  of  the  operator  and  assistants : 

1.  The  sleeves  are  rolled  w^ell  up  above  the  elbows  and  the  finger-nails  are 
trimmed  short  and  cleaned  thoroughly. 

2.  The  hands  and  forearms  are  then  scrubbed  carefully  and  vigorously,  for 
from  three  to  five  minutes,  with  warm  water  and  some  liquid  preparation 
of  green  soap — using  a  stiff  brush  and  giving  particular  attention  to  the 
irregularities  about  the  nails  and  knuckles  and  to  the  spaces  between  the 
fingers  at  their  junction  with  the  hand.  Where  the  brush  causes  undue  irri- 
tation of  the  skin,  gauze  is  preferable  for  scrubbing  the  arms,  but  not  the 
hands. 

3.  Then  the  soap  is  washed  off  with  sterile  water,  and  the  hands  and  fore- 
arms are  scrubbed  in  80  per  cent,  alcohol  with  gauze. 

4.  Then  they  are  scrubbed  in  bichloride  solution  (1  to  2000),  with  a 
brush  or  gauze. 

5.  The  sterile  gown  is  then  put  on,  the  hair  and  mouth,  and  neck  and 
greater  part  of  the  face  are  covered  with  gauze  by  the  nurse,  the  rubber 
gloves  and  sterile  muslin  sleeves  are  adjusted  and  the  operator  is  ready  to 
begin.  The  gauntlet  of  the  rubber  glove  is  brought  up  over  the  lower  end  of 
the  sterile  sleeve  to  hold  it  in  place,  and  the  arm  is  thus  securely  covered 
and  there  is  no  chance  for  any  skin  surface  to  come  in  contact  with  the 
wound. 

The  assistants  must  go  through  the  same  process. 

The  process  of  hand  disinfection  given  above  is  known  as  the  "alcohol- 


91g  INVASION  OF  THE  PERITONEAL  CAVITY 

bichloride"  method.    It  is  also  called,  from  its    originator,  the  Fiirbringer 
method. 

There  are  three  methods  of  hand-disinfection  which  are  much  used.  The 
thorough  scrubbing  with  green  soap  and  warm  water  is  common  to  all  of 
them.     The  further  steps  differ  as  follows: 

a.  The  "alcohol-bichloride"  method.  The  various  steps  in  this  method 
are  given  in  detail  above. 

b.  The  "permanganate  and  oxalic  acid"  method.  The  hands  and  forearms 
are  next  immersed  in  a  hot  saturated  solution  of  potassium  permanganate 
and  kept  there  until  the  skin  takes  on  a  dark  brown  color,  then  they  are 
immersed  in  a  hot  saturated  solution  of  oxalic  acid  until  the  skin  again  has 
its  natural  color.  The  oxalic  acid  is  washed  off  in  sterile  water  or  sterile 
lime  water,  and  the  hands  and  forearms  are  then  washed  in  bichloride  solu- 
tion (1-2000). 

c.  The  "chlorinated  lime  and  sodium  carbonate"  method.  After  the  pre- 
liminary scrubbing  a  tablespoonful  of  chlorinated  lime  is  taken  in  the  palm 
of  the  hand,  moistened  with  enough  water  to  make  a  thick  paste,  and  then  a 
piece  of  sodium  carbonate  (washing  soda)  about  the  size  of  the  thumb  is 
crushed  in  the  hand  and  rubbed  thoroughly  into  the  lime  paste.  This  mixture, 
containing  nascent  chlorine,  is  then  rubbed  vigorously  into  the  skin  of  the 
hands  and  forearms  for  three  to  five  minutes.  The  parts  are  then  washed  in 
sterile  water,  and  later  in  weak  ammonia  water  to  remove  the  chlorine  odor. 

As  to  the  choice  of  method  of  hand-disinfection,  that  is  largely  a  matter  of 
personal  preference.  Any  one  of  the  above  three  methods,  properly  carried 
out,  will  give  good  practical  hand-disinfection — i.  e.,  from  hands  and  arms 
so  prepared,  infection  will  rarely  if  ever  take  place.  The  important  thing 
is  not  which  method  is  chosen,  but  how  thoroughly  the  chosen  method  is  car- 
ried out.  I  have  used  all  three  methods,  and  very  decidedly  prefer  the 
"alcohol-bichloride"  method,  though  I  have  nothing  serious  to  say  against 
the  others. 

Absolute  disinfection  of  the  hands  and  arms  is  impossible  by  any  method, 
as  the  disinfection  is  necessarily  confined  to  the  superficial  layers  of  the  epider- 
mis. Bacteria  situated  in  tlie  deeper  layers  of  the  epidermis  may  work  to 
the  surface  during  the  course  of  the  operation;  hence  the  importance  of 
thoroughly  covering  the  prepared  hands  and  arms  with  rubber  gloves  and 
sterile  sleeves. 

REGULAR  STEPS 

In  Abdominal  Section. 

In  order  to  present  some  idea  of  tlie  main  features  of  this  important  thera- 
peutic measure,  I  shall  run  hastily  over  tlie  regular  steps  in  this  operation, 
and  later  consider  briefly  some  of  the  special  points  that  require  attention. 

The  regular  steps  incident  to  every  case  of  abdominal  section  are  as  fol- 
lows: 


REGULAR  STEPS   IN   ABDOMINAL  SECTION 


917 


1.  Anesthesia. 

2.  Incision. 

3.  Exploration. 

4.  Correction  of  pathological  condition. 

5.  Toilet  of  peritoneum. 

6.  Closure  of  incision. 

7.  Dressing. 


I'lg.  713.  The  Sate  Position  of  the  Arms  during  Anesthesia.  The  elbows  are  brought  to  the  patient's 
sides  and  the  forearms  rest  comfortably  against  the  chest,  where  they  are  held  by  the  sleeves  being  pinned  to 
the  gown 


1.    Anesthesia.   Ether  is  safer  than  chloroform,  and  is  to  be  preferred  in  all 
cases  except  where  there  is  some  definite  contra-indication. 

There  is  neither  space  nor  occasion  here  for  a  general  consideration  of  an- 


918 


INVASION  OF  THE  PERITONEAL  CAVITY 


esthesia.  There  is  one  point,  however,  that  I  think  advisable  to  call  attention 
to,  and  that  is  the  position  of  the  patient's  arms  during  anesthesia.  Many 
cases  of  paralysis  of  one  or  both  arms  following  anesthesia  have  been  re- 
ported— the  paralysis  lasting  for  many  months  and  sometimes  for  a  year.  It 
is  due  largely  to  faulty  position  of  the  arms  during  anesthesia.     This  is  a 


Fig.  714.     A  Dangerous  Position  of  the  .•Vrms  during  Anesthesia.     Many  cases  of  paralysis  of  one  or  both 
arms  from  this  position  have  been  reported. 


serious  matter  and  attention  should  be  called  to  it  in  every  work  dealing 
with  anesthesia — and  yet  it  is  seldom  mentioned.  In  1905  I  reported  two 
cases  of  such  brachial  paralysis  in  detail  to  the  St.  Louis  ]\Iedical  Society, 
called  attention  to  previous  work  and  investigations  on  the  subject,  and  demon- 
strated, directly  on  the  cadaver,  the  compression  of  the  brachial  plexus  by 


REGULAR  STEPS   IN   ABDOMINAL   SECTION 


919 


the  clavicle  when  the  arm  is  above  the  head.*  As  stated  in  the  article,  this 
has  long  been  recognized  as  the  cause  of  the  paralysis,  the  attention  of  the 
profession  generally  having  been  first  called  to  the  subject  by  Budinger  in 
1894.  Fig.  713  shows  the  safe  position  for  the  arms  during  anesthesia.  No 
case  of  paralysis  has  ever  occurred,  as  far  as  known,  when  the  elbows  were 
kept  to  the  side  as  here  indicated.  Fig.  714  shows  a  dangerous  position  of 
the  arms — the  position  the  arms  occupied  in  my  two  cases  and  in  most 
of  the  reported  cases  of  paralysis  affecting  the  brachial  plexus.    Figs.  715  and 


Fig.  715.  View  of  the  Dissected  Area  ia  a  Cadaver,  ia  wliich  the  arm  was  brought  above  the  head  as  shown 
in  Fig.  714.  C,  cla\icle.  R,  first  rib.  T,  transverse  process  of  first  dorsal  vertebra.  O,  outer  trunk  of  brachial 
plexus.  S,  stump  of  suprascapular  nerve.  G,  compression  groove  made  by  cla\icle  when  arm  was  above  the 
head.     (Crossen — Journal  of  Missouri  State  Medical  Association.) 


716  serve  to  call  attention  to  the  anatomical  features  of  the  trouble.  Fig.  717 
shows  another  dangerous  position  of  the  arm  during  anesthesia — this  posi- 
tion being  liable  to  lead  to  peripheral  paralysis  from  pressure  by  the  edge 
of  the  table. 

2.  Incision.     In  abdominal  section  for  pelvic  disease  the  incision  is  made, 
almost  invariably,  in  the  median  line.    All  parts  of  the  pelvis  may  be  reached 


*  Brachial  Paralysis  Following  Surgical  Anesthesia;  Report  of  Two  Cases 
of  Missouri  State  Medical  Assocation,  vol.  1,'No.  10,  1905, 


By  H.  S.  Crossen,  M.  D.— Journal 


920 


INVASION  OF  THE  PERITONEAL  CAVITY 


from  such  an  incision  and,  in  practically  every  case,  exploration  of  the  whole 
pelvis  should  be  made.  Ordinarily  the  incision  is  begun  about  midway  from 
the  umbilicus  to  the  symphysis  and  continued  downward  three  or  four 
inches.  If  there  is  no  large  solid  tumor,  the  incision  is  made  small  at  tirst,  but 
large  enough  to  admit  the  fingers  or  hand  into  the  pelvis  for  exploration.  As 
a  rule  the  primary  incision  is  about  four  inches  long.  If  the  abdominal 
walls  are  very  thin,  it  may  be  shorter ;  if  they  are  very  thick,  it  must  be 
longer. 

The  lower  the  incision  is  placed,  the  more  easily  the  deeper  portions  of  the 


Fig.  716.  Diagram  of  Left  Brachial  Plexus  from  Gray's  Anatomy.  F,  Probable  field  within  which  would 
occur  the  lesion  producing  the  symptoms  mentioned  in  the  reported  cases.  G,  Location  of  compression  groove 
in  this  cadaver.     (Crossen— /cmmaZ  of  Missouri  Slate  Medical  Association.) 


pelvic  cavity  may  be  reached,  but  the  incision  must  not  be  low  enough  to 
injure  the  bladder.  When  a  tumor  is  present,  the  bladder  may  be  drawn  up 
considerably ;  consequently  in  such  a  ease  the  incision  must  not  be  extended 
low  until  the  peritoneal  cavity  has  been  opened  and  the  bladder  located. 
If  it  is  thought  that  the  bladder  may  be  drawn  so  high  as  to  interfere  with 
the  ordinary  incision,  a  steel  bougie  may  be  introduced  into  the  bladder  and 
the  height  of  its  cavity  determined  before  the  incision  is  made. 
In  cutting  through  the  abdominal  -wall  it  is  not  necessary  to  strike  the 


REGULAR  STEPS   IN   ABDOMINAL  SECTION 


921 


tendinous  tissue  between  the  recti  muscles.  If  the  incision  is  made  a  little 
to  one  side  of  the  tendinous  center  and  passes  through  the  rectus  muscle  of 
that  side,  it  makes  little  difference.  Consequently,  no  time  should  be  lost 
trying  to  make  a  careful  dissection  exactly  in  the  median  line. 

The  incision  is  continued  through  the  skin  and  the  subcutaneous  fat 
and  fascia,  and  the  rectus  muscle  with  its  tendinous  sheath,  down  to  the 
loose  subperitoneal  fat.  When  the  subperitoneal  tissue  is  reached,  all  bleed- 
ing it  stopped,  and  the  subperitoneal  fat  and  connective  tissue  are  cut  through 
between  two  dissecting  forceps.     The  peritoneum  is  then  picked  up  with  the 


Fig.  717.     Another  Dangerous  Position  of  the  Arm  during  Anesthesia. 


dissecting    forceps    and  a  short    cut  is    made  in  it,    and  this    opening  in  the 
peritoneal  cavity  is  enlarged  by  scissors  or  knife. 

3.  Exploration.  When  the  proper  opening  has  been  made,  the  hand  is  in- 
troduced into  the  peritoneal  cavity  and  the  various  pelvic  organs  are  out- 
lined and  the  pathological  condition  determined  as  accurately  as  possible. 

4.  Correction  of  Pathological  Condition.  After  the  exploration  of  the  pelvic 
ca^dty  and  the  determination  of  the  exact  condition  present,  the  particular 
measures  to  be  employed  will  depend  on  the  nature  of  the  trouble — the 
various  affections  requiring  very  different  methods  of  treatment. 

5.  Toilet  of  the  Peritoneum.  All  blood  and  clots  are  sponged  out  of  the 
pehds  and,  as  far  as  practicable,  the  pedicle  ends  are  turned  under  and  all 
raw  surfaces  covered  with  peritoneum.  All  abdominal  pads  are  then  removed, 
the  intestines  are  permitted  to  come  back  into  the  peMs  (the  patient  having 


922 


INVASION  OF  THE  PERITONEAL  CAVITY 


been  lowered  from  the  Treudelenburg  posture)  and  the  omentum  is  spread  out 
in  its  proper  place. 

6.  Closure  of  Incision.  There  are  two  methods  of  closing  the  incision — (a) 
by  "through  and  through  sutures"  of  silkworm-gut  and  (b)  by  "tier  sutures" 
of  cat-gut  or  other  absorbable  material.  Except  in  hurry  cases,  where  it 
is  exceptionally  important  to  get  the  abdomen  closed  as  quickly  as  possible, 
the  preferable  method  is  the  latter — approximation  by  tier  sutures  of  cat-gut, 
with  or  without  two  or  three  tension  sutures  of  silkworm-gut. 


Fig.  718.     The   Abdominal   Dressing. 
Gauze  next  to  the  wound. 


The  Flat 


Fig.  719. 
Gauze. 


The  Abdominal  Dressing.     The  Rough 


7.  Dressing.  The  dressing  of  the  abdominal  wound  consists  of  a  large 
thick  dressing  of  sterile  gauze  over  the  wound  (Figs.  718,  719),  next  to  that 
a  layer  of  sterile  absorbent  cotton  (Fig.  720)  covering  the  anterior  surface 
of  the  abdomen,  and  over  that  a  medium-thick  layer  of  sterile  common 
cotton  to  turn  any  water  that  might  be  spilled  on  the  dressing  during  con- 
valescence and  to  give  even  elastic  pressure  at  all  points — the  whole  held  in 
place  by  a  binder  about  the  abdomen,  with  perineal  straps  to  hold  it  well 
down  (Fig.  721). 


SPECIAL  POINTS  IN   ABDOMINAL  SECTION 


923 


SPECIAL  POINTS 

In  Abdominal  Section. 

There  are  a  number  of  special  items  that  must  receive  careful  consideration 
by  every  one  doing  abdominal  section  work.  Among  these  may  be  mentioned 
the  following : 

1.  Drainage. 

2.  Shock. 

3.  Injury  to  adjacent  organs. 

4.  Foreign  bodies  in  abdomen. 


Fig.  720.     The  Abdominal  Dressing.     The  layer  of  Absorbent  Cotton. 


1.  Drainage.  The  rule  in  abdominal  surgery  is  never  to  drain  unless  there 
is  some  special  reason  for  it,  and  that  special  reason  must  be  a  very  strong 
one.  Experience  has  abundantly  shown  that  in  all  but  exceptional  cases 
the  best  results  are  obtained  by  closing  the  peritoneal  cavity  completely  and 
leaving  nature  to  carry  on  the  reparative  process  alone,  undisturbed  by  tubes 
or  gauze  or  other  form  of  drainage. 

That  small  percentage  of  cases  in  which  drainage  is  advisable  includes  the 
following  classes- 


924 


INVASION  OF  THE  PERITONEAL  CAVITY 


a.  Rapidly  spreading  inflammation  of  the  peritoneum  or  acute  general 
peritonitis.  In  such  cases  free  drainage  is  indicated,  and  as  a  rule  the  freer 
the  better. 

b.  Rupture  of  abscess  in  pelvis.  This  accident  happens  not  infrequently 
during  the  enucleation  of  an  inflammatory  mass  containing  pus.  In  some 
cases  the   pus  is   not   confined  in   any   removable   sac,  but   has  burrowed   in 


Fig.  721.     The  Abdominal  Dressing.     The  Binder  applied. 


various  directions  among  the  adherent  organs.  In  such  a  case  as  soon  as  the 
adhesions  are  separated  the  pus  flows  out  into  the  peritoneal  cavity. 

c.  Persistent  fr.ee  oozing  from  surfaces  left  after  the  enucleation  of  an  in- 
flammatory mass.  Here  the  effect  desired  is  pressure  rather  than  drainage, 
but,  as  the  end  of  the  gauze  used  for  pressure  must  be  brought  out  through 
the  abdominal  wound  or  through  the  vagina,  it  is  usually  referred  to  as  a 
drain  or  pack. 

2.  Shock.  The  principal  factors  in  shock  are  (a)  loss  of  blood,  (b)  ex- 
posure and  handling  of  abdominal  contents   and    (c)    long  anesthesia.     To 


SPECIAL   POINTS   IN    ABDOMINAL  SECTION  925 

avoid  shock,  therefore,  particular  atteutiou  must  be  given  to  the  following 
points : 

a.  Careful  hemostasis.  All  vessels  that  can  be  located  are  ligated  or  clamped 
before  they  are  divided.  In  cutting  through  ligated  tissues,  forceps  are  in 
readiness  to  catch  any  vessel  that  may  have  escaped  the  ligature  or  upon 
which  the  ligature  is  not  tight  enough. 

b.  Protection  of  the  abdominal  contents,  as  far  as  possible,  from  handling 
and  exposure.  The  Trendelenburg  posture  accomplishes  this  to  a  large  ex- 
tent. In  this  posture  the  intestines  and  omentum  gravitate  into  the  upper  part 
of  the  abdominal  cavity,  away  from  the  field  of  operation.  Those  parts  that 
still  tend  to  protrude  into  the  pelvis  are  held  out  of  the  way  by  gauze,  which, 
at  the  same  time,  serves  to  wall  off  the  pelvis  from  the  abdominal  cavity. 
When  the  intestines  are  unavoidably  permitted  outside  of  the  peritoneal 
cavity,  they  should  be  kept  covered  with  large  sterile  towels  soaked  in  hot 
saline  solution. 

c.  Minimum  duration  of  anesthesia.  To  cut  down  the  duration  of  the 
operation  and  consequently  of  the  anesthesia,  the  operator  should  work 
rapidly — as  rapidly  as  is  consistent  with  safety  and  accuracy — but  accuracy 
must  not  be  sacrificed  to  haste. 

3.  Injury  to  Adjacent  Organs.  The  ureter,  the  bladder  and  the  intestines 
are  the  organs  particularly  liable  to  injury  in  difficult  cases.  Ordinarily  an 
injury  of  any  of  these  organs  occurring  in  the  course  of  an  operation  must 
be  repaired  at  once  or  at  the  close  of  the  operation,  and  any  one  doing  pelvic 
surgery  must  be  prepared  to  immediately  take  care  of  the  injuries  mentioned. 

4.  Foreign  Bodies  Left  in  the  Abdomen.  The  absolute  certainty  of  the 
removal  of  all  articles  carried  into  the  peritoneal  cavity  is  a  subject  that 
deserves  most  careful  consideration.  It  is  surprising  how  easily  and  quickly 
the  intestinal  coils  will  enfold  an  object  and  carry  it  out  of  sight  and  touch. 

Sponges.  A  sponge  left  in  the  peritoneal  cavity  following  an  operation  con- 
stitutes one  of  the  most  deplorable  accidents  of  abdominal  surgery.  This 
is  not  a  new  subject.  Much  has  been  written  upon  it  and  many  cases  have 
been  reported,  and  many  suggestions  have  been  made  as  to  preventive  meas- 
ures. But  all  such  measures  hitherto  proposed  have  broken  down  under  the 
various  circumstances  and  vicissitudes  of  surgical  work,  as  evidenced  by  the 
records  subsequently  cited.  In  connection  with  this  subject  I  wish  to  call  at- 
tention to  the  following  facts : 

1.  Sponges  are  lost  in  the  peritoneal  cavity  much  more  frequently  than  is 
generally  supposed.  The  accompanying  table  of  reported  cases  (page  934) 
wnll  indicate  the  importance  of  the  subject.  And  it  must  be  kept  in  mind 
that  the  reported  cases  represent  only  a  small  proportion  of  the  recognized 
cases,  for,  naturally,  the  accident  is  not  given  publicity  except  where  there 
in  some  special  reason  for  doing  so.  In  any  large  body  of  surgeons  a  little 
experience  meeting,  in  w^hich  testimonies  are  freely  given,  will  bring  to  light 
a  number  of  unreported  cases  of  this  accident. 


926  INVASION  OP  THE  PERITONEAL  CAVITY 

Furthermore,  many  cases  are  not  even  recognized.  The  patient  dies  with 
evidence  of  peritonitis;  there  is  no  suspicion  of  any  foreign  body  having 
been  left  in  the  abdomen,  no  post-mortem  examination  is  made  and  the  death 
is  supposed  to  be  due  to  ordinary  peritonitis.  The  possibilities  in  this  direction 
are  indicated  by  the  fact  that  in  the  series  mentioned,  in  thirty-nine  of  the 
cases  the  accident  was  recognized  only  on  post-mortem  examination,  when 
the  sponge  was  found,  but  would  have  remained  unknown  had  there  been 
no   autopsy. 

2.  It  is  a  most  serious  accident.  In  the  large  series  of  cases  collected  more 
than  one-fourth  of  the  patients  died,  and  of  those  who  recovered  many 
went  through  weeks  and  months  of  suffering. 

3.  To  persons  outside  the  profession  the  accident  seems  absolutely  inex- 
cusable. They  can  understand  how  other  complications  may  arise,  such  as 
hemorrhage  or  sepsis  or  kidney  failure,  in  spite  of  every  precaution,  but  they 
can  imagine  no  reasonable  excuse  for  allowing  a  sponge  to  be  lost  in  the 
patient's  interior.  To  those  not  familiar  with  surgical  work  it  seems  past 
belief  that  the  surgeon  would  carry  into  the  peritoneal  cavity  anything  the 
removal  of  which  was  not  provided  for  with  absolute  certainty. 

The  growing  cognizance  of  the  public  in  regard  to  the  occurrence  of  this 
accident  and  the  feeling  in  regard  to  the  responsibility  for  it  are  reflected 
in  the  increasing  number  of  lawsuits  connected  therewith  (see  Chapter  XVII). 

4.  There  has  hitherto  been  no  sure  preventive  method  which  was  appli- 
cable in  all  the  circumstances  of  abdominal  surgery.  The  list  of  preventive 
measures  recorded  later  shows  that  much  thought  has  been  given  to  devising 
means  for  preventing  this  accident.  Rules  interminable  have  been  proposed, 
and  expensive  and  cumbersome  racks  and  stands  devised  for  the  purpose. 
Not  one  of  these  devices,  however,  has  proven  absolutely  safe,  for  the  reason 
that  in  their  use  the  certain  removal  of  all  sponges  carried  into  the  abdomen 
depends  on  the  studied  attention  of  the  oi)erator  or  on  a  system  of  attentive 
co-operation  among  assistants  or  nurses.  While  such  attentive  co-operation 
is  entirely  feasible  under  ideal  conditions  and  with  ideal  persons,  the  fact 
remains  that  it  is  not  secured  and  is  not  likely  to  be  secured  under  the  variable 
circumstances  of  abdominal  work.  The  many  emergencies  which  arise  in 
the  course  of  abdominal  operations,  the  changing  assistants  and  nurses,  the 
hurried  operations  at  night  in  the  hospital  with  short  help,  the  operations  in 
private  homes  where  the  patient  cannot  be  gotten  to  the  hospital  at  all — all 
these  conditions  play  havoc  with  safety  arrangements  depending  upon  a 
nicely-balanced  system  of  rules  and  co-operation  or  on  the  use  of  cumbersome 
racks  or  stands. 

There  is  not  space  here  to  take  up  in  detail  the  various  ways  in  which  mis- 
takes have  occurred;  suffice  it  to  say  tliat  a  review  of  the  eases  where  de- 
pendence was  placed  on  counting  shows  an  appalling  list  in  which  a  sponge 
was  left,  because  one  was  liastily  torn  in  two  and  one-half  forgotten,  or  an 
extra  one  was  primarily  included  in  the  bundle  and  missed  in  the  counting, 


THE  SPONGES  IN  ABDOMINAL  SECTION  927 

or  an  extra  one  was  secured  for  an  emergency  during  the  operation,  or  some 
loose  piece  of  gauze,  not  intended  for  intraperitoneal  use,  slipped  in  while 
near  the  wound,  or  a  mistake  Avas  made  in  the  final  count  of  the  sponges  re- 
moved. It  is  astonishing  what  a  sliglit  inattention  may  lead  to  a  sponge  being 
left,  and  the  consequent  death  of  the  patient. 

The  method  of  attaching  a  tape  to  each  sponge  and  then  fastening  a  forceps 
to  the  tape  and  at  the  same  time  to  the  abdominal  sheet,  is  the  method 
probably  in  most  general  use.  It  has  a  record  of  many  accidents — the  tape 
pulled  off  the  sponge,  or  there  was  a  failure  to  attach  the  forceps,  or  the  for- 
ceps failed  to  hold  well.  In  one  case  recorded  the  sponge,  tape  and  forceps 
were  all  lost  in  the  cavity. 

The  difficulty  of  guarding  absolutely  against  leaving  a  sponge  in  the  abdo- 
men is  such  that  entire  security  against  this  fatal  accident  is  counted  one  of 
the  unsolved  problems  of  abdominal  work.  Practically  all  writers  on  the 
subject  state  that  there  is  no  guaranty  against  its  occurrence,  even  in  routine 
hospital  work  and  wdth  all  the  rules  of  co-operation  and  the  special  apparatus 
designed  to  prevent  it.  Neugebauer,  in  a  most  exhaustive  consideration  of  the 
subject,  comes  to  the  conclusion  that  the  accident  is,  to  a  certain  extent,  un^ 
avoidable.  Schachner,  in  an  excellent  paper,  states,  "So  long  as  surgery 
continues  an  art,  just  so  long  wall  foreign  bodies  continue  to  be  unintentionally 
left  in  the  abdominal  cavity."  In  an  article  published  recently,  Findley 
states,  "In  former  years  the  abdominal  surgeon  was  seriously  disturbed  by 
well-grounded  fears  of  secondary  hemorrhage  and  sepsis,  but  surgery  has 
mastered  these  problems  to  a  large  degree  and  they  are  little  feared  and 
seldom  experienced.  Now  it  is  the  thoughts  of  the  sponge  that  disturb  the 
night's  repose  wdien  the  report  comes  that  something  has  gone  wrong  with 
our  patient.  The  operator  never  can  rid  himself  of  the  feeling  of  uncertainty 
as  to  the  possibility  of  leaving  a  sponge."  This  expresses  very  well  the 
feeling  of  those  who  have  given  attention  to  this  subject,  and  particularly  of 
those  who  have  personally  experienced  the  accident  and  have  thus  been 
brought  face  to  face  with  a  concrete  exemplification  of  the  inadequacy  of  the 
usual  methods. 

The  continued  occurrence  of  this  fatal  accident  and  the  failure  of  the 
preventive  methods  in  general  use  constitute  sufficient  reason  for  my  calling 
attention  to  a  method  which  I  have  used  with  much  satisfaction  for  the  past 
four  years.  This  method  gives  entire  security  and  at  the  same  time  is  simple 
and  inexpensive,  and  is  effective  in  all  conditions  of  abdominal  work — in  the 
emergency  operation  in  the  country  with  unfamiliar  assistants,  as  well  as  in 
the  routine  hospital  w^ork.  The  failure  of  the  safety  methods  in  general  use  is 
due  to  their  dependence  upon  sustained  attention  concerning  the  sponges, 
which  attention  on  the  part  of  the  surgeon  cannot  be  given  to  the  sponges,  for 
it  is  required  elsew^here.  A  method,  to  be  effective  under  all  circumstances, 
must  be  practically  automatic,  insuring  the  removal  of  all  gauze  without 
particular  attention  on  the  part  of  any  one  at  the  time  of  the  operation. 


928  INVASION  OF  THE  PERITONEAL  CAVITY 

The  Method. 

The  underlying  principle  of  this  method  is  the  elimination  of  all  detached 
pads  and  sponges.  In  place  of  them  I  use  long  strips  of  gauze,  each  strip 
packed  into  a  small  bag  in  such  a  way  that  it  may  be  drawn  out  a  little  at 
a  time  as  needed. 

I  was  led  to  a  study  of  the  subject  and  the  adoption  of  this  method  by 
an  unfortunate  experience.  Following  the  usual  technique,  I  operated  for  years 
without  accident,  but  five  years  ago  I  left  a  gauze  pad  in  the  abdomen.  The 
case  was  one  of  diffuse  pelvic  suppuration,  requiring  extensive  drainage, 
and,  fortunately,  the  pad  was  discovered  and  extracted  through  the  drainage 
opening  about  two  weeks  later.  The  patient  recovered  without  serious  result 
from  the  accident — but  the  lesson  was  not  lost.  I  determined  to  find  some 
method  that  would  really  prevent  such  an  accident — a  method  which  would 
be  entirely  under  the  control  of  the  operator  and  first  assistant  (a  greater 
division  of  responsibility  increases  the.  danger)  and  one  which  would  occasion 
no  delay  in  the  closing  steps  of  the  operation.  There  had  to  be  taken  into  con- 
sideration the  large  pads  for  holding  the  intestines  out  of  the  way  and  the 
small  pads  and  gauze  pieces  for  sponging.  In  place  of  several  large  pads  for 
packing  back  the  intestines,  I  adopted  the  large  roll  of  gauze,  then  in  iise  by 
a  number  of  operators,  and  found  it  satisfactory. 

The  matter  of  the  small  pads  and  sponges,  however,  was  not  so  easily  dis- 
posed of.  I  felt  that  it  was  imperative  to  find  some  method  that  would  do 
away  entirely  with  dependence  on  the  counting  of  the  sponges  at  the  close 
of  the  operation.  As  long  as  there  was  dependence  on  counting  of  the  numer- 
ous small  pads  and  sponges  there  would  be  mistakes,  and  consequently 
sponges  would  occasionally  be  left  in  the  cavity.  To  eliminate  this  hazardous 
dependence  on  counting,  and  to  provide  a  method  that  Avould  make  the  leaving 
of  a  sponge  in  the  abdomen  practically  impossible,  was  not  an  easy  task.  I 
worked  over  the  problem  for  the  greater  part  of  a  year.  I  tried  various 
methods  in  common  use  for  keeping  track  of  the  small  pads  and  sponges, 
such  as  clamping  an  artery  forceps  to  a  tape  attached  to  each  sponge,  attach- 
ing a  heavy  ring  to  each  tape  before  stei-ilization,  clamping  each  tape  or  a 
corner  of  each  sponge  to  the  sterile  sheet  about  the  wound,  and  the  like.  But 
I  did  not  find  any  such  method  that  was  practical  under  all  circumstances  and 
absolutely  safe. 

It  then  became  evident  to  me  that  if  safety  were  to  be  secured,  the  detached 
pads  and  sponges  must  be  eliminated  entirely.  In  pursuance  of  that  idea  I 
devised  the  method  here  described.  The  principle  of  this  method  is  that 
no  detached  piece  of  gauze  shall  enter  the  abdominal  cavity.  Each  piece  of 
gauze  introduced  for  sponging  is  simply  part  of  a  very  long  piece,  the  greater 
part  of  which  is  always  outside  the  cavity.  To  make  assurance  doubly  sure, 
I  have  recently  put  the  large  roll  of  gauze  above  mentioned  into  a  bag,  similar 
to  the  bags  for  the  narrow  strips,  except  that  it  is  open  on  the  side.  As  now 
used,  therefore,  the  set  consists  of  the  following : 


THE  SPONGKS    FOR   ABDOMINAL   SECTION 


929 


Gauze-strip  Sponges  for  Abdominal   Section. 
i'-our  narrow  strips— 10  yds.  long,  M  in.  wide— (J  tliicknesses. 
One  wide  strip — 5  yds.  long,  9  in.  wide — 4  thicknesses. 
Have  another  set  of  strips  (4  narrow  and  1  wide)  in  reserve. 

For  the  Narrow  Strips  the  yard-width  of  gauze  is  divided  into  two  strips,  and  each 
of  these,  when  folded  to  six  thicknesses,  is  about  three  inches  wide.  For  the  Wide  Strip 
the  full  yard-width  of  gauze  is  used — when  folded  to  four  thicknesses  it  is  nine  inches 
wide.     Turn  in  all  raw  edges  so  that  no  raveling  can  be  left  in  the  abdominal  cavity. 

Pack  each  Narrow  Strip  into  a  separate  small  cloth  bag,  5  in.  wide  and  10  in.  deep, 
(Fig.  722,  a)  and  attach  a  large  safety  pin  to  the  bottom  of  the  bag.  The  safety  pin  is  to 
pin  the  bottom  of  the  bag  to  the  abdominal  sheet  at  operation.  Make  the  bag  of  extra 
heavy  muslin  or  drilling,  and  sew  with  French  seams  to  avoid  raveling  on  the  inside. 
The  end  of  the  strip  first  introduced  to  bottom  of  the  bag  should  be  fastened  there 
securely  by  stitching  through  and  through.  Then  pack  the  strip  firmly  into  the  bag 
(Fig.  723)  in  such  a  way  that  it  will  come  out  easily,  a  little  at  a  time  as  needed  (Fig. 
726).   Four  of  these  filled  bags  belong  in  each  set  (Fig.  725,  a). 

For  holding  the  Wide  Strip  use  a  bag  6  in.  by  10  in.,  and  open  on  the  side  instead 
of  at  the  end  (Fig.  722,  b).  Fold  the  strip  back  and  forth,  thus  forming  a  narrow  pile 
about  three  inches  wide  (see  Fig.  724).  Fasten  one  end  of  the  strip  securely  to  the 
bottom  of  the  bag  by  sewing  through  and  through.  Then  place  the  folded  strip  in  the 
bag  in  such  a  way  that,  when  pulled  upon,  it  will  come  out,  a  little  at  a  time,  as  a  wide 
strip  suitable  for  packing  back  the  intestines.  Fold  over  the  open  side  of  bag  and  pin 
with  two  large  safety  pins  (Fig.  725,  b).  The  safety  pins  are  for  fastening  two  corners 
of  the  bag  to  the  abdominal  sheet  (Fig.  727). 

One  wide  strip  and  four  narrow  strips  constitute  one  set  and  are  to  be  wrapped 
together  in  a  cloth  for  sterilization  in  the  usual  way.  Have  also  an  extra  sterilized  set 
in  reserve.  At  the  operation  the  bag  containing  the  wide  strip  is  to  be  placed  in  hot 
normal  saline  solution.     The  narrow  strips  are  to  be  used  dry. 


Fig  722.  The  Cloth  Bags  Empty.  A.  Bag  for  each  Narrow  Strip.  It  i.s  five  inclifs  v.i.lf  and  ten  inches 
deep,  and  is  open  at  the  top.  It  is  made  of  extra  heavy  muslin  and  is  sewed  with  French  seanis,  so  that  there 
is  no  chance  for  any  raveUng  to  be  pulled  out  with  the  gauze.  B.  Bag  for  the  Wide  Strip.  It  is  six  inche.s 
by  ten  inches,  and  is  open  at  the  side.  This  bag  is  the  same  as  those  for  the  narrow  strips  except  that  it  is 
one  inch  wider  and  is  open  at  the  side  instead  of  at  the  end. 


930 


INVASION  OF  THE  PERITONEAL  CAVITY 


Fig.  723.  PackiiiK  the  Narrow  Strip  into  the  bag. 
The  end  of  the  strip  is  caught  witli  a  forceps  and  car- 
ried to  the  bottom  of  the  bag,  where  it  is  fastened 
securely  by  sewing  through  and  through,  and  then 
successive  portions  are  rapidly  packed  in  with  the 
forceps.  When  packed  in  thus,  the  gauze  strip  may 
be  drawn  out  a  little  at  a  time  as  needed. 


liK.  724.  Tlift  Wide  Strip  folded  and  ready  to  put 
in  the  bag.  One  end  of  the  strip  is  first  introduced 
to  the  bottom  of  the  bag  and  fastened  there  securely 
by  sewing  through  and  through.  Then  the  whole 
strip,  folded  as  shown,  is  placed  in  the  bag.  When 
the  strip  is  folded  in  this  way  it  will,  when  pulled 
upon,  come  out  as  a  wide  strip,  suitable  for  packing 
back  the  intestines  (see  Fig.  727.) 


Fig.  72.3.  A  Sft  of  diin/Cc-Strip  Siiongcs.  .\.  Four  Niirrow  Strips.  Tlie  safety-pin  at  the  bottom  of  each 
bag  is  for  fastening  the  bag  to  the  abdominal  sheet  (see  Fig.  727).  B.  Wide  Strip.  The  two  safety-pins 
closing  the  bag  are  u.sed  later  for  fastening  tlie  comer.s  of  the  bag  to  the  abdominal  sheet  (see  Fig.  727.) 


GAUZE-STRIP  SPONGES   FOR  ABDOMINAL  SECTION 


931 


-^rr^' 

— r--:-;:n-n 

Fig.  726.  Method  of  Using  the  Gauze-Strip 
Sponges.  Just  before  the  incision  is  made,  a  bag 
containing  a  Narrow  Strip  is  fastened  at  the  side  of 
the  abdomen  by  pinning  the  bottom  of  the  bag  to 
the  sterile  sheet-  If  desired,  the  top  of  the  bag  may 
be  pinned  in  Hke  manner.  The  mouth  of  the  bag 
lies  conveniently  near  the  wound,  but  not  in  the  way. 
The  end  of  the  gauze  strip  is  caught  with  the  forceps 
or  fingers  and  pulled  out  as  needed  for  sponging,  as 
here  indicated.  In  a  case  where  but  little  sponging 
is  required,  one  bag  will  be  sufficient.  In  a  case 
where  more  sponging  is  likely  to  be  required,  it  is 
well  to  fasten  a  bag  on  each  side  of  the  abdomen  at 
the  beginning  of  the  operation.  The  bag  on  each 
side  gives  a  sponge  immediately  at  hand  for  both  the 
operator  and  the  first  assistant.  The  convenience 
of  this  will  be  appreciated  by  those  who  have  had  to 
wait,  in  an  emergency,  for  a  sponge  to  be  handed  to 
them.  [For  photographing,  the  checked  toweling 
was  used  instead  of  the  usual  white  abdominal 
sheet,  so  as  to  show  the  white  bag  and  strip  better 
by  contrast.] 


Fig.  727.  Method  of  Using  the  Gauze-Strip 
Sponges.  As  fresh  portions  of  the  strip  are  drawn 
out  for  use,  the  soiled  portions  are  not  cut  off,  but 
simply  dropped  down  beside  the  bag  and  off  the 
table.  It  is  the  continuity  of  the  strip  that  insures 
safety,  hence  the  strip  should  not  be  cut  during  the 
course  of  an  operation.  Trouble.some  accumulation 
of  folds  of  the  strip  about  the  wound  (with  conse- 
quent tangling  \\ith  instruments)  may  be  prevented 
by  always  dropping  the  soiled  portion  outside  the 
field  close  to  the  bag,  as  here  shown.  This  photo- 
graph shows  also  the  Wide  Strip  in  place,  ready  to  be 
used  for  packing  back  the  intestines  or  walling  off  a 
large  area  or  any  other  purpose  for  which  large  pads 
are  ordinarily  used.  The  bag  containing  the  wide 
strip  is  preferably  wrung  out  of  hot  saline  solution 
just  before  use.  It  is  then  laid  on  the  abdomen, 
opened,  two  corners  pinned  to  the  abdominal  sheet, 
as  here  sbcvn,  and  the  strip  drawn  out  as  required. 
No  detached  pads  or  other  pieces  of  gauze  are 
allowed  about  the  operative  field,  hence  none  can 
be  carrierl  into  the  abdominal  cavity  tobe  left  there. 


This  method  eliminates  all  chance  of  leaving  a  piece  of  gauze  in  the  abdo- 
men, for  a  large  part  of  the  strip  is  always  outside  the  cavity,  and  the  end  is 
fastened  securely  outside.  An  important  point  is  that  the  sure  removal  of  all 
gauze  is  practically  automatic.    It  does  not  depend  on  the  accuracy  of  a  hur- 


932  INVASION  OF  THE  PERITONEAL  CAVITY 

ried.  counting  of  sponges  at  the  close  of  the  operation  nor  on  catching  each 
sponge  or  sponge-tape  with  a  forceps  as  it  is  put  into  the  cavity,  nor  on  a 
studied  "watching  what  sponges  go  in  and  what  sponges  come  out  of  the 
cavity."  Those  methods  that  depend  for  safety  on  the  observance  of  compli- 
cated rules  or  on  the  strict  following  of  a  regular  routine,  or  on  the  constant 
attention  of  the  operator,  have  all  broken  down  under  the  difficulties  and 
vicissitudes  of  abdominal  surgery,  as  the  reported  cases  clearly  show.  A 
method,  to  be  safe  and  suitable  for  general  use,  must  be  practically  automatic 
in  the  removal  of  all  gauze  carried  into  the  cavity,  must  be  comparatively 
inexpensive  in  materials  and  preparations,  must  be  fairly  simple  and  con- 
venient in  use,  and  must  be  applicable  in  every  environment,  including  emer- 
gency work  in  the  country.  These  requirements  are  met  by  the  method  here 
described. 

The  dangers  from  hemorrhage  and  sepsis  in  clean  cases  have  been  largely 
done  away  v^^itll  through  improvements  in  technique,  and  now  this  other 
serious  menace  in  abdominal  work  should  be  eliminated.  The  patient  has  a 
right  to  demand,  and  is  demanding  as  the  many  law  suits  show  (see  Chapter 
XVII),  that  real  protection  be  afforded  against  leaving  a  sponge  in  the  abdo- 
men. It  seems  only  justice  to  those  who  intrust  themselves  to  our  care  that 
we  should  provide  absolute  security  against  this  fatal  accident,  so  far  as  such 
security  is  practically  attainable. 

It  simplifies  the  preparations  for  abdominal  section — all  the  many  pads  and 
sponges  of  various  sizes  being  replaced  by  five  strips  of  gauze.  The  gauze  is 
simply  folded  and  then  tacked  by  a  few  stitches  at  each  end  to  prevent  unfold- 
ing. Nurses  as  a  rule  welcome  the  method,  stating  that  it  is  much  less  trouble- 
some than  the  sewing  of  the  numerous  small  pads  and  sponges.  The  bags  may 
be  used  again  and  again  after  sterilization. 

Many  questions  have  been  asked  me  concerning  this  method  by  surgeons 
contemplating  its  use,  but  there  is  room  here  for  only  two. 

"Do  not  the  methods  in  general  use  give  practical  safety?" — The  facts 
previously  mentioned  and  the  table  of  cases  subsequently  given  answer  that 
question  to  a  large  extent.  Hitherto  there  has  not  been  a  method,  practically 
applicable  in  all  the  vicissitudes  of  abdominal  surgery,  which  would  entirely 
prevent  this  accident.  Practically  all  autliorities  state  that  it  is  to  a  certain 
extent  unavoidable.  Notwithstanding  all  the  methods  hitherto  proposed, 
many  lives  are  still  being  sacrificed  to  this  accident.  In  spite  of  widespread 
interest  in  the  subject  in  recent  years  and  of  much  study  and  investigation 
of  it  and  several  excellent  papers  by  different  authorities,  there  has  been  no 
signal  advance.  Ten  years  ago  operators  were  using  the  same  preventive 
measures  now  commonly  employed.  The  sponges  were  couiit(Hl,  tapes  were 
attached  to  the  sponges  tluil  Avcre  counted,  forceps  were  attjiclied  to  Hie  tapes 
tluit  were  attached  to  Hie  sponges  tli;it  were  eonnted,  etc.  Yet  willi  nil  these 
complicated  precautions,  many  sponges  were  left  in  the  cavity,  as  the  records 
show. 


LONG   INSTRUMENTS    FOR   ABDOMINAL  SECTION  933 

''Is  not  the  strip  of  gauze  exteucling  i'roin  the  forceps  to  the  bag  inconveu- 
ient  aud  in  the  way  Avheu  sponging?" — Sometimes  it  is  in  tlie  way  to  a  slight 
extent,  but  not  as  much  as  woukl  at  first  appear.  Any  new  method  seems 
somewhat  awkward  at  first,  and  this  is  no  exception  to  tlie  ruU;.  However, 
in  my  experience  so  far,  I  have  not  found  any  situation  in  which  there  was  seri- 
ous interference  with  satisfactory  sponging  or  Avith  any  other  operative  mani])- 
ulation.  Like  any  other  important  step  in  technic,  it  should  he  studied  until 
it  is  clearly  understood  before  an  attempt  is  made  to  use  it.  There  are  two 
particular  points  that  may  be  mentioned.  To  prevent  the  accumulation  of 
loose  folds  of  gauze  in  the  vicinity  of  the  wound,  the  used  portion  of  the  strip 
should  always  be  dropped  outside  the  field,  close  to  the  bag.  Again,  w^lien 
taking  hold  of  a  fold,  to  sponge  wdth,  draw  it  out  of  the  bag  for  some  distance, 
so  that  it  can  be  introduced  into  the  abdomen  as  far  as  desired  freely  and 
wdthout  tension. 

Forceps.  In  about  one-fourth  of  the  recorded  cases  of  a  foreign  body  left 
in  the  abdomen  the  article  left  w^as  a  forceps  or  piece  of  an  instrument,  or 
other  small  object  used  about  the  w^ound.  This  calls  attention  forcibly  to  the 
fact  that  small  instruments  should  not  be  allowed  about  an  open  abdominal 
wound.  Neugebauer  long  ago  called  attention  to  this  danger  of  small  instru- 
ments, and  urged  the  use  of  long  instruments  exclusively  in  abdominal  work. 

]\Iany  surgeons  have  adopted  this  safety  measure,  but  there  are  many  others 
who  seem  to  give  no  thought  to  the  matter,  and  continue  to  use  numerous 
small  instruments  in  this  dangerous  locality.  It  may  not  be  possible  at 
present  to  entirely  prevent  the  accident  of  leaving  some  article  of  the  surgical 
armamentarium  in  the  abdomen,  but  it  is  possible  to  reduce  the  danger  to  a 
minimum  by  the  use  of  long  instruments  exclusively,  and  it  seems  to  me  that 
all  those  wdio  are  engaged  in  abdominal  surgery  should  be  led  by  common 
prudence  to  adopt  this  simple  expedient.  The  details,  as  carried  out  in  my 
own  work,  are  as  follow^s :  Every  instrument  used  about  the  wound  is  long — 
so  long  that  a  portion  of  it  is  practically  always  outside  the  abdominal  cavity. 
Again,  if  by  accident  such  an  instrument  should  slip  entirely  into  the  cavity, 
its  length  is  such  that  it  would  almost  certainly  be  felt  when  the  hand  is 
carried  into  the  cavity  for  the  final  palpation  before  closing.  All  the  artery- 
forceps,  dissecting-foreeps,  tenaculum-forceps,  pedicle  needles,  scissors  and 
other  instruments  for  internal  work  are  from  six  and  a  half  to  eight  inches 
long,  the  shortest  being  the  large  dissecting  scissors  (six  and  one-half  inches). 
The  shortest  instrument  used  anywhere  about  the  wound  is  the  scalpel  (six 
inches),  wdiich  is  laid  aside  as  soon  as  the  peritoneal  cavity  is  open.  The 
needles  and  Murphy  buttons  are  not  brought  near  the  wound,  except  when 
held  wnth  a  forceps  or  wnth  a  suture  attached.  No  IMichel  clamps  (for  hold- 
ing rubber  tissue  or  gauze  along  the  wound  margin)  or  other  small  unattached 
objects  are  allow^ed  near  the  wound  as  long  as  the  peritoneal  cavity  is  open. 

The  following  table  wall  serve  to  call  attention  to  the  importance  of  the 
subject  of  foreign  bodies  left  in  the  abdominal  cavity  at  operation. 


934  REPORTED  CASES  OF  A  FOREIGN  BODY  LOST  IN  THE   ABDOMINAL  CAVITY 

Abdominal  Section.     Sponges  Left. 


No. 

1859 

Operator* 

Character  of 
Operation. 

Article  Lost. 

When  and  How  Removed. 

Result. 

1 

Fehr 

7 

Sea  sponge. 

Details  not  given.     Mentioned  by 

7 

Fehr  and  quoted  by  Olshausen. 

2 

1877 

? 

7 

Sea  sponge. 

Found  at  secondary  operation  by  G. 
Braun.  c. 

7 

3 

1883 

Lawson  Tait. 

7 

Sponge. 

Sponge  missed.     Four   hours  later 
wound  was  reopened  and  sponge 
recovered,  a. 

7 

4 

1884 

H.  P.  Wilson. 

Ovarian  cyst  and 
pregnancy. 

Pieces  of  sea 
sponge. 

Five  months  after  operation,  pieces 
passed  through  sinus  in  scar.  a. 

Recovery 

5 

1884 

T.  G.  Thomas. 

Carcinoma  of 
spleen. 

Pieces  of  sea 
sponge. 

Found  at  autopsy.     Patient  died 
four  days  after  operation.  Car- 
cinoma inoperable,  a. 

Death. 

6 

1884 

Howltz. 

Uterine  necrosis. 

Sponge. 

Found    at    autopsy.     Details    not 
given.       aDed  by  Wilson,  a. 

Death. 

7 

1884 

London  surgeon. 

7 

Sponge. 

Found  at  autopsy .t  Cited  by  W.T. 
Howard  and  also  by  Wilson,  a. 

Death 

8 

1889 

Bridden. 

Myomectomy. 

Sea  sponge,  7  cm . 
wide. 

Found  at  autopsy.     Patient  died 
sixth  day  of  peritonitis,  c. 

Death. 

9 

1892 

Pilate. 

Hysterectomy. 

Compress,  8 
inches  long. 

Passed  per  rectum,   nine  months 
after  operation,  a. 

Recovery 

10 

1892 

Salin. 

Ovarian  tumor. 

Gauze  napkin. 

One    year    later,    gauze    removed 
through  an  abscess  sinus,   with 
subsequent    fecal    fistula    which 
healed,  a. 

Recovery 

11 

1892 

French  surgeon. 

Salpingitis. 

Two  strips  of 
gauze. 

Eight  months  later,  35  cm.  strip  of 
gauze    extracted    per    vaginam, 
still  later  intestine  resected  and 
10  cm,  strip  found  within,  a. 

Recovery 

12 

1892 

French  surgeon. 

Uterine  fibroid. 

Compress,  26  cm. 
long. 

Eight  months  later  passed  per  rec- 
tum,   without    alarming    symp- 
toms at  any  time.  a. 

Recovery 

13 

1892 

French  surgeon. 

Myomectomy. 

Sponge. 

A  few  hours  after  operation    ab- 
domen was  reopened  and  sponge 
located   and   removed,  a. 

Recovery 

14 

1892 

Quinn. 

Pyosalpinx. 

Napkin. 

Found  at  autopsy.   Was  suspected. 
Death  on  third  day  with  symp- 
toms of  se\ere  dysentery,  a. 

Death. 

15 

1893 

Terrier. 

7 

Sponge. 

Found     at     autopsy.     Death     on 
third  day  from  peritonitis,  a. 

Death. 

16 

1893 

? 

Hysterectomy. 

Compress. 

Secondary  operation  by   Michaux 
for     painful     abdominal    mass. 
Compress  found  within  intestine. 

Death. 

17 

1895 

Eisner. 

Fibroid  and  ova- 
rian cyst. 

Pad,  7x8  inches. 

Six  months  later,  passed  per  rec- 
tum.    Progress   of   mass   noted 
along    course    of    colon   in   last 
month,  a. 

Recovery 

18 

1896 

MacLaren 

Ovarian  cyst  and 
retroversion. 

Gauze  sponge  6x6 
inches. 

Ten  days  after  operation,  expelled 
from  rectum.     Secondary  opera- 
tion three  months  later  for  ad- 
hesions, a. 

Recovery 

19 

1896 

? 

7 

Sea  sponge. 

Details  not  given.     Two  cases  were 
observed  by  MacLaren  at  autop- 
sy in  New  York  Woman's  Hos- 
pital. 

Death. 

20 

1896 

? 

7 

Sea  sponge. 

See  preceding  note. 

Death. 

21 

1896 

Severeano 

Ovarian  sarcoma. 

Two  compresses, 
each  130x30 
cm. 

After  some  months,  one  compress 
was  extracted  from  a  persistent 
sinus,  and  three  weeks  later,  the 
other,  a. 

Recovery 

22 

1897 

Tuholske. 

7 

Sponge. 

One  hour  after  operation,  sponge 
missed.     Abdomen  reopened  and 
sponge  found  and  removed. 

Recovery 

23 

1897 

? 

? 

Sponge. 

Details  not  given.  H.  C.  Coe  states 
that  in  autopsy  work  he  found 
a  sponge  in  five  cases.     Death 
by  sepsis  in  each.  a. 

Death. 

24 

1897 

? 

7 

Sponge. 

See  preceding  note.  a. 

Death. 

25 

1897 

? 

7 

Sponge. 

See  preceding  note.  a. 

Death. 

26 

1897 

? 

7 

Sponge. 

See  preceding  note.  a. 

Death. 

27 

1897 

? 

•    7 

Sponge. 

See  preceding  note.  a. 

Death. 

28 

1897 

7 

7 

Sponge. 

Twelve  years  later,  passed  per  rec- 
tum.    Reported  by  Hefting,  a. 

Recovery 

29 

1897 

Linquist. 

Tubal  pregnancy. 

Gauze  compresf5. 

Two  months  later,  passed  per  rec- 
tum, a. 
Sponge  missed  before  patient  re- 

7 

30 

1897 

McMurtry. 

Ovarian  cyst. 

Flat  sponge. 

Recovery 

covered    from    anesthetic.     Su- 

tures   clipped    and    sponge    re- 
moved . 
Four  hours  later,  sponge  missed. 

31 

1897 

R.  B.  Hall. 

Appendicitis. 

Sponge. 

Recovery 

Abdomen  reopened  and  sponge 

32 

1898 

Wiggin. 

Secondary  opera- 
tion for  silk 
ligature. 

Gauze  strip. 

renio\'ed . 
Some  weeks  after  operation,  gauze 
strip  was  removed  from  a  per- 
sistent sinus.     Lawsuit,  c. 

Recovery 

REPORTED  CASES  OF  A  FOREIGN  BODY  LOST  IN  THE  ABDOMINAL  CAVITY.  935 

Abdominal  Section.     Sponges  Left. 


"o  t" 

Characfer  of 

No. 

1898 

Operator* 

Operation. 

Article  Lost. 

When  :uid  How  Removed.             Result. 

33 

Schramm. 

Hysterectomy. 

Compress. 

Four  weeks  later,  operated  for  a'Recovery 

mass,    which   proved   to  be  the 

compress,  a. 

34 

1898 

Leopold. 

? 

Compress. 

Removed  by  seconrlary  operation.  Recovery 
Was  near  li\er.  a.                         < 

35 

1898 

? 

Cesarean  section. 

Compre.ss. 

Found   at   autop.sy   by  Olshausen.' Death. 
Caused  fatal  peritonitis,  a. 

36 

1898 

Brosin. 

Bicornuate 

Compress,  20  cm. 

Six  months  later,  expelled  from  a  Recovery 

nteru.s. 

long. 

persistent  sinus,  a. 

37 

1898 

Roesger. 

Uterine  fiijroid. 

Fragments  of  sea 
sponge. 

After    six    months,    particles    dis-  Recovery 
charged     through    a    persistent 
sinus,  n. 

38 

1898 

Bolt. 

Hysterectomy  for 

Gauze  sponge. 

Several    months    later,    secondary  Death. 

fibroid. 

operation.     Sponge  found  in  in- 
testine.       Resection.        Death 
from  shock,  a. 

39 

1898 

Schroeder. 

Oophorectomy. 

Gauze  sponge. 

Secondary  operation  some  months'        7 
later    for    an    abdominal    mass. 
Sponge  in  ma.ss.  a. 

40 

1898 

? 

? 

Sponge. 

Found  at  autopsy  by  Thiersch,  a.  Death. 

41 

1898 

? 

7 

Sponge. 

Boldt  stated  in  1898  that  he  knew,        7 
of  five  unpublished  cases  (among 
colleagues)  of  foreign  bodies  left 
in  abdomen,  a. 

42 

1898 

? 

? 

Sponge. 

See   preceding   note   of   five   ca.ses         7 
(count   three  sponges,   and   two 
forceps),  a. 

43 

1898 

? 

? 

Sponge. 

See  preceding  note.  a.                       \        7 

44 

1898 

? 

? 

Sponge. 

Boldt    states    that    pathologist    in  Death. 
New   York  Hospital  found   for- 
eign   body    at    autopsy   in   two 
cases  (1  sponge,  1  forceps.)  a. 

45 

1898 

? 

7 

Sponge. 

Boldt    cites    two    cases    in    which         7 
abdomen       was       immediately 
opened,    and    forgotten    article 
removed  (1  sponge,  1  forceps.)  a. 

46 

1898 

Eckstein. 

Ovarian  cyst, 

Sponge  20x40 

Five     weeks  later  extracted  from  Recovery 

twisted  pedicle. 

cm. 

sinus  in  scar.     Count  of  spongesi 
after  operation,  stated  "correct." 
d. 
Two  and  one-half  years  later  re-  Recovery 

47 

1899 

Buschbeck. 

Tubal  pregnancy. 

Large  compress. 

moved  from  .sinus  in  scar.  a. 

48 

1899 

Meinert. 

? 

Mull  compress. 

Three  weeks  later,  secondary  oper-  Recovery 
ation  for  mass  in  right  lower  ab- 
domen.    Proved     to     be     com- 
press, a. 

49 

1899 

Rehn. 

Pyosalpinx. 

Compress,  1  m. 
square. 

Four     months     later     secondary  Recovery 
operation.          Compress    found 
within    intestine.     Resection    of 
40  cm.  a. 

50 

1899 

Kader. 

Salpingitis. 

Compress,  size  of 
handkerchief. 

Sinus  present  for  six  months.  Later  Death. 
the  compress  passed  per  rectum. 
Death  from  peritonitis,  c 

51 

1899 

Busch. 

Uterine  fibroid. 

Mull  compress. 

Two  months  later,  passed  per  rec-  Recovery 
tum,  after  much  trouble,  a. 

52 

1899 

Fritsch. 

? 

Sponge. 

One  year  later  removed  by  second-  Recovery 
ary  operation.     Cited   by   Kay- 
ser.  c.                                                j 

53 

1899 

Fritsch. 

? 

Sponge. 

No  details  given.     Cited  by  Kay-j        ? 

ser.  c.                                                1 
Two     years     later     removed     by  Recovery 

54 

1899 

Fritsch. 

? 

Sponge. 

secondary  operation.     Cited  by 

Kayser.  c.                                       ' 

55 

1899 

Gillette. 

Tubal  pregnancy. 

Sponge. 

Eighteen    months   later,    removed  Recovery 

by  secondary  operation.     Law- 

suit. 

56 

1900 

Merttens. 

Pelvic  suppura- 
tion. 

Compress. 

Five   months   later,   operation   for 
abdominal    mass.           Compress 
witliin    intestine.     Resection   of 
intestine,  a. 

Recovery 

57 

1900 

Wunderlich. 

Ovarian  cyst. 

Compress,  21x100 
cm. 

Three  months  later,  compress  was 
pas.sed  per  rectum,  c. 

Recovery 

58 

1900 

Wunderlich. 

Cystectomy. 

Linen  cloth. 

Found    at    autopsy.         Death    on 
third  day.     No  evidence  of  peri- 
tonitis. '(/. 

Death. 

59 

1900 

H.  A.  Kelly. 

Pehic  suppura- 
tion. 

Marine  sponge. 

Some  davs  later,   wovmd   was   re-]Reco\ery 
opened  because  of  disturbance.' 
Sponge  found  anrl  removed,  c. 

60 

1900 

Kelly. 

Ovarian  cyst. 

Large  gauze  pad. 

Two    and    a    half    months    later, i Recovery 
operation   for   abdominal   ma.ss. 
Mass  contained  sponge  and  ab- 
scess, t. 

936  REPORTED  CASES  OF  A  FOREIGN  BODY  LOST  IN  THE  ABDOMINAL  CAVITY. 

Abdominal  Sectiox.     Sponges  Left. 


No. 


Operator* 


Character  of 
Operation. 


Article  Lost. 


AViien  and  How  Removed. 


Cca 


61  1900  Kelly 

62 

63 


87 


1900!  Assistant  to 
Kelly. 


1900 


1900  ? 

1900  Spencer  Wells. 


1900  Winkle. 
1900! 

1900 
1900 


1900  ? 

1900  ? 

1900  Krasowski. 


1900  Frankenhauser. 
1900  Bier. 

1900  Bier. 
1900  ? 

1900  .\tlee. 
1900  Borysowicz. 


1900  Karl  Braim. 
1900  ? 

1900  ? 

1900  George  J.  Engle- 
mann. 


1901  Beck. 
1901  ? 

1901  Everke. 

1901  Everke. 

1901  Le  Conte. 


1901 


1901 
1901 


1901 


M.  D.  .Mann. 


H.  C.  Coe. 


1901 

1901  Coe. 
1901  [Coe. 
19011  Roberts. 


Ovarian  cyst  and 
appendicitis. 

Fibroid  of  ab- 
dominal wall 


Myomectomy. 


Gauze  pad. 


Gauze,  360  gm. 
weight. 


Sponge. 


Sponge. 
Sponge. 


Sponge. 


Wound  of  omen-     Sponge, 
tum. 


Myomectomy. 
Tubal  pregnancy. 


Pelvic  tuberculo- 
sis. 

Two  laparot- 
omies, pyosal- 
pinx. 

Ovariotomy. 


Gauze  napkin. 
Gauze. 


Gauze. 
Gauze. 
Sponge. 


Sponge. 

Mull  compre.ss, 
1x13^  m. 

Gauze  strip. 

Iodoform  gauze, 
52x44  cm. 


Sponge. 


Uterine  fibroid.       Gauze  sponge. 


Sponge. 
Sponge. 


Ovarian  cyst. 


Gauze  napkin. 
Small  sponge. 


Fibroid  and  pyo-    Sponge, 
salpinx. 

Sponge. 


Pyosalpinx. 


Gauze  compress. 


Cesarean  section.    I  Napkin. 


Tubercular  peri- 
tonitis. 


? 
7 
Hy.sterectomy. 


Gauze  strip,  1 
yd.  wide  and  5 
ft.  long. 

Flat  sponge. 

Gauze  pad. 
iGauze  pad. 

, Gauze  pad. 


Large  gauze  pad. 

Gauze  sponge. 
Gauze  pad. 
Sponge. 


Result. 


Five  days  later,  operation  for  fever 
and  a  mass.  In  mass  was 
sponge  and  abscess,  c. 

One  month  later,  secondary  opera- 
tion for  mass  in  abdomen.  Con- 
tained sponge  and  abscess,  c. 

Reeves  Jackson  described  two  cases 
in  which  a  sponge  was  found  at 
autopsy,  a. 

Set  preceding    note.  a. 

Sponge  missed.  Abdomen  re- 
opened next  day  and  sponge 
found,  a. 

Found  at  autopsy.  Details  not 
given,  a. 

Two  weeks  later,  sponge  was  ex- 
tracted from  an  abdominal  sinus. 
a. 

Found  at  autopsy  by  Kijweski. 
Details  not  given,  a. 

Przewoski  found  gauze  in  cavity 
at  three  autopsies  following  ab- 
dominal section,  a. 

See  preceding  note.  a. 

See  preceding  note.  a. 

Prof.  Krasowski  was  legally  pro- 
ceeded against  for  leaving  a; 
sponge  in  the  abdomen,  a. 

Removed  by  secondary  operation. 
Details  not  stated,  a.  j 

Six  months  later,  secondary  opera- 
tion. Compress  found  witliin 
intestine,  c. 

Long  time  afterward,  gauze  passed 
per  rectum,  c. 

Secondary  operation  for  intestinal 
obstruction  by  Chaput.  Gauze 
found  within  intestine.  Intes- 
tine incised,  c. 

Found  at  autopsy.  At  operation 
a  sponge  was  torn  in  two  by  an 
assistant,  a. 

Three  weeks  later,   sponge  was? 
passed     per     rectum.     Lawsuit 
threatened,  a. 

Found  at  autopsy,  a. 

Found  at  autopsy.  Reported  by 
W.  T.  Bull.  a. 

Found  in  a  secondary  laparotomy 
by  Dmochosky.  a. 

Sponge  missed  at  operation. 
Searched  for  carefully  but  not 
found.  Found  at  autopsy  four 
days  later,  a. 

One  month  later,  sponge  was  ex- 
tracted from  an  absce.ss  in  scar. 

Sponge  finally  passed  per  rectum. 
Cited  by  Beck,  who  was  called  to 
see  patient  by  Leusman. 

Later  recovered  by  seconriary  oper- 
ation. Details  not  given.'  Law- 
suit, c. 

Foimd  at  autopsy.  Death  on  fifth 
day  from  splanchnic  irritation. 
No  sepsis,  c. 

Year  later,  strip  removed  from  a 
persistent  fecal  fistula.  Sug- 
gestion made  that  accident  was 
beneficial  to  iiatient.  b.  c. 

Removed  next  day.  No  harm  re- 
sulted, b.  c. 

Cited  by  M.  D.  Mann.  /).  c. 

Cited  by  M.  D.  Mann  in  his  letter 
to  ScliiU'hner.  b.  c. 

Some  niontlis  later,  pad  was  dis- 
charged through  sinus  in  scar. 
Cited  by  .M .  1).  Mann.   h.  c. 

Four  weeks  later,  pad  was  felt  un- 
der scar,  and  remo\ed.  b.  c. 

Particulars  not  {.'i\pn.  b.  c. 

Particulars  not  given,  b.  c. 

One  week  lider,  siK)ns.'e  was  ex- 
tracted froin  an  al)scess  in  the 
\\<iuii(|.   Ii.  r. 


Death. 

Recovery 

Death. 


Death. 
Recovery 


Death. 


Death. 

Death. 


Death. 
Death. 
? 


Recovery 
Recovery 

Recovery 
Recovery 


Death. 
Death. 


Death. 
Recovery 

9 

Recovery 

Death. 

Recovery 

Recovery 

Death. 
Death. 

Recovery 

Recovery 

Recover.v 
Rero\ery 
Reco'very 


REPORTED  CASES  OF  A  FOREIGN  BODY  LOST  IN  THE  ABDOMINAL  CAVITY.  037 

AuiJOMixAL  Section.     Sponges   Left. 


No. 

96 

97 

98 
99 

100 


101 

102 


103 
104 


105 
106 


107 


108 
109 
110 
111 


112 

11.3 

114 
115 

116 

117 

118 

119 

120 

121 
122 

123 

124 


P« 
1901 


Operator* 


1901 
1901 

1901 


Roberts. 

F.  \V.  SainueL 

H.  Grant. 
T.  S   Bullock. 


1901  Weir. 
1901  Weir     ? 


1901  Weir. 

I 
1901  7 


1901  7 

1901  R.  Matas. 


1901  G.  R.  Fowler. 


1901  Fowler. 
1901  Fowler. 
1901  Vander  Veer. 
1901|Vander  Veer. 


1901  C.  P.  Noble. 

190l!  ? 

1901'  ? 

1901  E.  Lewis. 

1901  A.  MacLaren. 

1901  Gerster. 

1901  ? 

1901  B.  C.  Hirst. 


1901iW.  M.  Polk. 
1901  ? 


1901 
1901 


W.  T.  Bull. 
Baldwin. 


125  j  1901  Munde. 
126jl90l'price. 

127|l90l!Price. 

128  1902  Ru.s.sell. 

i     ! 

129  1902  Lindfors. 

130  19031  Kayser. 


Character  of 
Operation. 


Pelvic  inflamma- 
tion. 

Fibroid  and  pyo- 
salpinx. 

Gunshot  wound 

of  abdomen. 

Ventral  hernia. 


.\ppendiciti? 
Appendicitis 


Appendicitis. 


? 

? 
? 
Carcinoma  of 
uterus. 


Appendicitis. 

Inoperable  car- 
cinoma. 


Ectopic  preg- 
nancy. 

Cholecyst  ostomy. 


Sarcoma  of  kid- 
ney. Laparotomy 


Oophorectomy. 


Extrauterine 
pregnancy. 

Postoperative 
hernia. 


.\rticle  Lost. 


Pad. 


Flat  sponge. 


Two  sponges. 

Gauze  pad,  7x5 
inches. 

Gauze  pad. 


Sponge. 
Gauze  pad 

Gauze  pad. 

Sponge. 


sponge, 
lodotorm-gauze 

strip. 

Gauze  pad. 


Gauze  pad. 
Gauze  pad. 
Sea  sponge. 
Sponge. 


Sea  sponge. 

Two  sponges. 

Piece  of  gauze. 
Sponge. 

Piece  of  gauze. 

Iodoform  pack- 
ing. 

Gauze  pad  and 
attached  clamp 

Sponge. 


Gauze  pad. 

Half  of  a  sponge. 
Pad. 

Large  flat  sponge 
Sponge. 

Towel,  1x2  ft. 
Sponge. 

Sponge. 

Lint  sponge. 

Compress. 
Gauze  roll. 


When  and  How  Removed 


Re.sult. 


Death. 


Death. 


Death. 
Recovery 


Recovery 


Death. 
Reco\ery 


Death. 
Recovery 


Death. 
? 


Found  at  autoi)sy,  by  Irwin  Abell. 
Death  78  hours  after  operation, 
with  syiuptoms  of  ileus,   h.  c. 

Found  at  autopsy.  Death  the 
third  day,  with  symptoms  of 
nephritis,  b.  c. 

Found  at  autopsy.  Patient  died 
a  few  hours  after  operation,    b.  c. 

Eight  days  later,  pad  was  ex- 
tracted from  a  sinus  in  the 
wound,  b.  c. 

Three  weeks  later  pad  appeared  at 
drainage  wound  and  was  ex- 
tracted, b.  c. 

Details  not  gi\en.  b.  c. 

Remo\ed  in  five  days.  Details  not 
given,  b.  c. 

Five   months   later,    pad    was   re-  Recovery 
moved.     Details  not  given.  b.c.\ 

In  his  letter  to  Schnachner,  Weir  Death. 
cites  two  ca.se  in   wjiich  he  re- 
moved a  sponge,  b. 

See  preceding  note.  6. 

Six  months  later,  strip  was  ex- 
tracted from  a  persistent  sinus. 
b.c. 

In  letter  to  Schnachner,  Fowler 
mentions  three  cases.  Details 
not  given,  b.  c. 

See  preceding  note.  b.  c. 

See  preceding  note.  b.  c. 

Patient  died  of  peritonitis.  6.  c. 

One  year  later,  secondary  opera- 
tion for  recurrence  of  carcinoma. 
Sponge  found,  b.  c. 

Some  weeks  later,  secondary  opera- 
tion and  sponge  found,  b.  c. 

Cited  by  J.  B.  Murphy.  Details 
not  given.  6.  c. 

Cited  by  J.  B.  Murphy.  6.  c. 

Fourteen   days   later,    sponge   ex-  Recovery 
traded  from  sinus  in  scar.  b.  c.  i 

Three  weeks  later,  gauze  was  ex-Recovery 
tracted  from  drainage  tract.  6.  c. 

Found  at  autopsy.  Details  not 
given.  6.  c. 

Cited  by  Frank  Hartley.  Details 
not  given,  b.  c. 

Found  at  autopsy.  Sponge  torn 
in  two  by  assistant.  Sponges 
counted  and  reported  "correct." 
&.  c. 

.\fter  some  weeks,  secondary  opera-        7 
tion    for    fecal    fistula.     A    few 
days  later,  the  sponge  was  passed 
per  rectum,  b.  c. 

Sponge  torn  in  two  at  operation.         ? 
Details  not  given,  b.  c. 

Later  extracted  from  a  persistent'Recovery 
.sinus  in  scar.     Ob.served  by  A.  J.j 
Boyd.  b.  c.  \ 

Five    days    later,    discoverefl    in  Recovery 
drainage  tract  and  removed,  b.  c. 

Baldwin,  of  Columbus,  Ohio,  was         ? 
made  defendant   in   a   law   suit 
because  of   sponge    left    in    ab- 
domen, b. 

Four  weeks  later  removed  from  a. Recovery 
suppurating  sinus,     h.  c. 

Sponge  missed  .soon  after  closing 
wound.  Reoi)ened  and  sponge 
remoi'ed.  b.  c. 

Similar  to  preceding  case.  Price 
cites  two  cases  in  his  letter  to 
Schnachner.  b.  c. 

Six  months  later,  secondary  opera- 
tion. SponTC  remo\-ed  from 
within  intestine,  c. 

Later  extracted  from  a  pelvic  ah-  Recovery 
scess  by  %aginal  incision,  c. 


Death. 


Death. 


Recovery 


Recovery 


Recovery 


iTwo    and    a    half    months    later, 
secondary  oi>eration.  Gauze 

roll  within  intestine.     Re.<;ection. 


Recovery 


938 


REPORTED  CASES  OF  A  FOREIGN  BODY  LOST  IN  THE  ABDOMINAL  CAVITY. 
ABDOinNAL  Section.     Sponges  Left. 


1 


No. 

Qtti 
1903 

Operator* 

Character  of 
Operation. 

.Article  Lost. 

When  and  How  Removed. 

Result. 

131 

Beckmaun. 

? 

Napkin. 

Beckman  stated  that  he  had  three 

? 

cases  in  which  napkin  was  lost 

in  abdominal  ca\-ity. 

132 

1903 

Beckmann. 

? 

Napkin. 

See  preceding  note.          No  details 
given. 

See  preceding  note.          No  details 
given. 

Secondary  operation  for  fecal  fis- 
tula.    Sponge  found  within  in- 

? 

133 

1903 

Beckmaim. 

? 

Napkin. 

? 

134 

1903 

Fick. 

Perityphilitis. 

Cotton  compress. 

Recovery 

testine,  c. 

135 

1903 

Gruning. 

Uterine  myoma. 

Marley  tampon. 

Some   weeks   later,   after  pain  in 
lower  abdomen,  tampon  passed 
per  rectum. 

Recovery 

136 

1903 

Schaefer. 

Myomectomy. 

Gauze  napkin. 

Found  at  autopsy,  two  years  later. 
Accompanied       by       intestinal 
necrosis,  c. 

Death. 

137 

1904 

Ahfeld. 

? 

Gauze  sponge. 

Prof.    Ahfeld   was  subjected   to  a 
lawsuit   in    1903,    because   of   a 
sponge  left  in  the  abdomen,  c. 

? 

138 

1904 

Corson. 

Ectopic  preg- 
nancy. 

Sponge,  18x36  in. 

Two    and    a    half    months    later, 
sponge  passed  per  rectum,  d. 

Recovery 

139 

1904 

? 

Kidney  opera- 
tion. Lapa- 
rotomy. 

Sponge,  1  meter 
long. 

Forty-six    days    later,    secondary 
operation  for  painful  mass  and 
ileus.     Sponge  within  intestine. 
Resection,  d. 

Recovery 

140 

1904 

Reise. 

Extrauterine 
pregnancy. 

Sponge. 

Ten  months  later,  secondary  opera- 
tion   for    ovarian    cyst    and    in- 
flammation.    Sponge  found  near 
sigmoid,  d. 

Recovery 

141 

1904 

Thorne. 

Abdominal 
tumor. 

Sponge. 

After   several    months,    secondary 
operation.     Sponge  found.  Law- 
suit, d 

Recovery 

142 

1904 

Winter. 

Hysterectomy  for 
fibroid. 

Sponge. 

Found   at   autopsy.     Death   three 
weeks   after   operation,    of   em- 
bolus, d. 

Death. 

143 

1906 

Waldo. 

Hysterectomy  for 
fibroid. 

Towel. 

Some   weeks  later  was   extracted 
through  sinus  in  scar.     Sponges 
counted  and  "correct."   d. 

Recovery 

144 

1906 

? 

Salpingectomy. 

[odoform-gauze 
strip. 

Two  years  later,  found  at  second- 
ary operation.     Cited  by  Waldo. 
d. 

Later  discharged  per  vaginam. 

? 

145 

1906 

Ward. 

? 

Sponge. 

Recovery 

146 

1906 

Brothers. 

Ectopic  preg- 
nancy. 

Pad. 

Six    weeks    later,    pad    protruded 
from  opening  in  lower  part  of 
scar. 

? 

147 

1906 

Grandin. 

? 

Pad. 

Two  and  a  half  years  later,  found 
encysted  in  the  omentum. 

Recovery 

148 

1906 

Grandin. 

? 

Towel,  with  hos- 
pital name  on. 

Three     weeks     later,      secondary 
operation  for  mass  imder  liver. 
Mass  contained  towel. 

Recovery 

149 

1906 

? 

Sponge. 

One  and  a  half  years   later,  opera- 
tion   by    .A.mann    for    supposed 
fibroid.     Proved  to  be  a  sponge. 
d. 

Eighteen    weeks   later,    secondary 

Recovery 

150 

1906 

Landau. 

Ovariotomy. 

Napkin. 

Recovery 

operation   for     fecal    a    fistula. 

Sponge  found,  d. 

151 

1907 

MacLaren. 

Hysterectomy. 

Sponge,  12  in. 
square 

Found   at   autopsy,   up  under  the 
liver.     Death  on  the  fourth  day. 

Death. 

152 

1907 

Crossen. 

Pelvic  suppura- 
tion. 

Gauze  pad. 

Two    weeks   later,    appeared    in 
drainage    tract    and    was   ex- 
tracted. 

Recovery 

153 

1907 

d'Antona. 

Carcinoma  of  liv- 
er. 

Gauze  napkin 
40x70  cm. 

Found  at  autopsy.     Death  in  one 
month    from    carcinoma,    peri- 
tonitis   and    adjacent    pleuritis. 
Two  lawsuits,  d. 

Death. 

154 

1907 

Dobrucki. 

Ovarian  cy.st. 

Sponge. 

Three     weeks     later     extracted 
through  sinus  in  scar.  d. 

Recovery 

155 

1907 

Janczewski. 

Ovarian  cyst  and 
pyosalpinx. 

Gauze  napkin. 

Twenty-one    days    later    removed 
from   abscess   in    wound.   (Janc- 
zewski,     assistant      to      Neuge- 
bauer.)   d. 

Recovery 

156 

1907 

Poten. 

Myomectomy. 

Sponge. 

Found    at    autopsy.     Death    after 
six  weeks  from  bronchitis.     No 
peritonitis,  d. 

Death. 

157 

1907 

Prochownick. 

7 

Sponge - 

Sponge     missed.     Wound     imme- 
diately    reopened     and     sponge 
found,  d. 

Recovery 

158 

1907 

Russian  opera- 
tor. 

Gauze  compre.s.s. 

No  details.     Reported  by  Neuge- 
bauer.     Operator  did  not   wish 
name  given,  d. 

'  ? 

159 

1907 

Polish  operator. 

7 

Gauze  compress. 

Details   not    given.     Reported    by 

7 

1 

Neugebaucr.  d.                               ' 

REPORTED  CASES  OF  A  FOREIGN  BODY  LOST  IN  THE  ABDOMINAL  CAVITY.  939 

Abdominal  Section.     Spo.nges  Left. 


"o  t, 

No. 

1907 

Operator* 

Operation. 

Article  Lost. 

When  and  How  Removed. 

Result. 

160 

Sippel. 

Broad  ligament 

lodoform-gauze 

Six  weeks  later,   the  gauze   strip 

Recovery 

tumor. 

pack. 

passed  per  rectum,     d. 

1(51 

1907 

Berlin  operator. 

.A.dnexal  mass. 

Gauze  strip. 

Later  extracted  from  the  bladder 
by  W.  Stuckel.  d. 

? 

162 

1907 

L.  Meyer. 

Cesarean  section. 

Mull  napkin. 

Found     at     autopsy.     Death     on 
the    Jourth    day  of    peritonitis. 
Sponges  counted  and  "correct." 
d. 

Some    months    later    removed    by 

Death. 

163 

1908 

? 

? 

Five-foot  roll  of 

? 

gauze. 

secondary  operation,  which  was 
witnessed  by  J.  C.  Morfit. 

164 

1908 

7 

Appendicitis. 

Iodoform  gauze, 
1  sq.  yd. 

Found  at  secondary  operation  in 
Mount     Sinai     Hospital.     Wit- 
nessed by  M.  G.  Seelig. 

Recovery 

165 

1908 

? 

Appendicitis. 

Piece  of  sea 
sponge. 

Extracted  from  sinus  at  Mt.  Sinai 
Hospital,  in  1900,  by  M.  G. 
SeeUg. 

Details      not       stated.        Patient 

Recovery 

166 

1908 

Schooler. 

? 

Pad,  16  in.  sq. 

Recovery 

awarded    11500    damages    by    a 

167 

1908 

Hageboeck. 

Appendicitis. 

Sponge. 

Abscess   formation   and    death   of 
patient.     Three  trials  for  $50,000 
damages. 

Death. 

168 

1908 

Fiiidley. 

? 

Strip  of  gauze, 
5  ft.  long. 

Ten  days  later,   found   at    second- 
ary operation.     Sponges  counted 
and   stated    "correct,"    but   one 
roll  had  been  cut  in  two. 

Recovery 

169 

1908 

? 

Ovarian  cysts 
(bilateral.) 

Two  gauze  pads. 

Removed  by  secondary  operation, 
six    weeks    later.     Followed    by 
fecal    fistula,    which    finally 
healed. 

Recovery 

170 

1908 

? 

Pelvic  tuberculo- 
sis. 

Small  sponge. 

One  year  later,  secondary    opera- 
tion for  persistent  sinus.  Sponge 
found.     Death  from  operation. 

Death. 

171 

1908 

? 

Gallstone  opera- 
tion. 

Small  sponge. 

Found    at    autopsy.     Death    after 
four  days  from  peritonitis. 

Death. 

172 

1908 

Rieck. 

Extrauterine 
pregnancy. 

Compress,  15x20 
cm. 

No  symptoms.     Four  months  after 
operation,  compress  passed  per 

Recovery 

rectum. 

Abdominal  Section.     Forceps  and  Other  Articles  Left. 


173 

1880 

174 

1886 

175 

1892 

176 

1896 

177 

1896 

178 

1897 

179 

1898 

180 

1898 

181 

182 

1898 
1898 

183 

1898 

184 

1898 

Mariani. 
Olshausen. 
French  surgeon. 
MacLaren. 

? 

Morestin. 
Herczel. 

? 


Nussbaum. 


Ovariotomy. 
Ovariotomy. 

9 

ectomy. 
? 
Salpingitis. 


Drainage  tube. 
Forceps. 
Forceps. 
Artery  forceps. 
Forceps. 
Artery  forceps. 
Clamp. 
Forceps. 


Forceps. 
Forceps. 


Forceps. 
Drainage-tube. 


Drainage  tube  slipped  inside  and 
was    overlooked.     One    week 
later  it  passed  per  rectum,  a. 

Ten  months  later  passed  per  rec-  Recovery 
tum,  after  only  two  weeks  dis- 
turbance, a. 

Immediately  after  the  operation, 
the  abdomen  was  reopened  to 
recover  a  forceps,  a. 

Two  years  later,  secondary  opera-  Recovery 
tion.     Found  forceps  perforating 
cecum,  ileum,  and  appendix. 

Ferrier  stated  that  one  of  his  asso- 
ciates had  recovered  a  forceps 
left  in  the  abdomen. 

Three    years    later,    forceps    were  Recovery 
passed    per    rectum,    after    per- 
sistent suffering,   a. 

One  and  a  half  years  later,  re- 
moved by  secondary  operation. 
a. 

Boldt  stated  in  1898  that  he  knew 
of  five  cases  among  colleagues, 
in  which  a  foreign  body  was  left. 
(Count  two  forceps.)  a. 

See  preceding  note.  a. 

Boldt  stated  that  a  pathologist  in  Death, 
a   N.   Y.   hospital   had   found   a; 
foreign  body  at  autopsy  in  two  Death, 
cases.     (Count    1    forceps,     1 
sponge.)  a. 

Boldt     mentioned    two    cases    in'        ? 
which    abdomen    was    reopened  I 
to  recover  article  left.     (Count  l! 
forceps,  1  sponge.)  n.  ! 

Two  months  later,  patient  herself  Recovery 
drew  it  out  of  an  abdominal  si- 
nus, after  a  night  of  dancing,  n.   I        


940  REPORTED  CASES  OF  A  FOREIGN  BODY  LOST  IN  THE  ABDOMINAL  CAVITY. 

Abdominal  Section.     Fobceps  and  Other  Articles  Left. 


No. 

185 

1898 

186 

1898 

187 

1899 

Operator* 


Character  of 
Operation. 


Article  Lost. 


When  and  How  Removed. 


Bode. 


American  sur- 
geon. 

Lassallette. 


188:1900  H.  A.  Kelly. 


189  1900  G.  Braun. 

190  1900  Sepp. 


191  1900!Cushing. 

192  1 1900  Nussbaum. 
!         ! 

193 i 1900  ? 

194  1900  ? 


195 

1900 

Spencer  Well 

196 

1900 

Spencer  Well 

197 

1900 

Terrier. 

198 

1900 

Terillon. 

199 

1900 

Winkle. 

200 

1900 

? 

201 

1900 

Kosinski. 

202 

1900 

Kosinski. 

20.3 

1900 

? 

20-1  1901  M.  D.  Mann. 
Schnachner. 

7 
7 

Nussbaum. 

Prochownick. 
7 


Large  Obroid. 
Hysterectomy. 

OvArian  cyst. 


Ovariotomy. 

? 

? 
? 

Ovariotomy. 

Ovariotomy. 


Inoperable  tu- 
mor. 


Uterine  fibroid. 


Strangulated 
hernia. 


Myomectomy. 
Ovarian  cyst. 

Ovariotomy. 


Drainage-tube. 

'Diamond  ring. 
Forceps. 
Forceps. 


Bulldog  forceps. 
Xelaton  catheter. 


Seal  ring. 

.Artery  forceps. 

Piece  of  glass 
irrigator. 

Forceps. 

.\rtery  clamp. 
Artery  clamp. 
Forceps. 

Forceps. 

Forceps. 
Richelot  clamp. 

.\rtery  forceps. 


'Two  artery 
forceps. 


Artery  forceps. 

Hemostat. 
Forceps. 

i 

;  Forceps. 

Forceps. 

Seis.sors. 

Forceps. 
Pean  forceps. 

Forceps 

Forceps. 
.\rtery  forceps 


Tube  slipped  into  wound  and  was 
forgotten.  After  a  few  days, 
wound  was  reopened  and  tube 
found,  a. 

Remained  six  months  in  the  ab- 

1     domen.     Other     details     not 
given. 

Found  at  autopsy.  Criminal  trial. 
Operator  sent  to  prison.  (See 
Legal  Complications.)  c. 

Found  in  drainage  tract  after  a  few 
days.  In  operation  to  extract 
it/ patient  died  from  hemor- 
rhage, a. 

Forceps  found  at  autopsy,  a. 

Found  in  bladder  \\\x\i  some  silk 
ligatures,  several  months  later. 
Catheter  had  been  used  to  ligate| 
pedicle,  a. 

Some  j-ears  after  the  laparotomy! 
the  ring  was  recovered  by  in- 
cision in  vaginal  vault,  a. 

Nine  months  later,  passed  per  rec- 
tum, a. 

Two  weeks  later  lound  at  autopsy 
by  Kyewski.  Patient  died  ^ith 
symptoms  of  nephritis,  a 

ReeVes  Jackson  mentions  a  case  in 
which  autopsy  revealed  a  forceps 
left  in  the  ca\ity.  a. 

One  month  later,  the  clamp  was 
found  in  the  bladder,  a. 

Clamp  missed.  Wound  reopened 
next  day  and  clamp  found,  a. 

Eight  days  later,  forceps  was  dis- 
charged spontaneously  from  re- 
gion of  umbilicus,  a. 

Neugebauer  states  that  Terillon 
forgot  a  forceps  in  the  abdominal 
cavity,  a. 

Later  discharged  spontaneously 
from  an  abscess,  a. 

Details  not  given.  Simply  stated 
that  clamp  was  left  beliind.  a. 

Four  months  later  forceps  ex- 
tracted from  an  abdominal  ab- 
scess, a. 

Two  secondary  operations,  in  the 
second  of  which  patient  died  of 
hemorrhage.     Criminal    trial. 
(See  Legal  Complic.)  a. 

Found  at  secondary  operation  by 
another  operator,  who  related 
the  case  to  Neugebauer.  a. 

Removed  in  one  hour  after  opera- 
tion.    No  trouble  resulted,  h.  c. 

Seven    months    later,      secondary 
operation     for     ileus.     Forceps 
found      within  intestine.  Re- 
moved by  incision.  6.  c. 

Removed  at  autopsy,  after  a  lap- 
arotomy. Witnes-sed  by  J.  A. 
Wveth.'  b.  c. 

Eight  and  a  half  years  later,  part 
of  forceps  was  extracted  from  an 
abdominal    sinus.     Cited    by 
Ellison,  d. 

Later,  secondary  operation.  Scis- 
sors found.  'Cited  by  Senn  in 
letter  to  Schachner,  b.  c. 

Six  months  later  half  of  forceps 
extracted  from  sinus  in  scar.  c. 

Six  years  later,   secondary  opera- 
tion  for  ileus.     Forceps   found. 
Patient    died.     Reported    by 
Hedlund.  (/. 

Seven  years  later,  forceps  felt 
through  abdominal  wall.  Ex- 
tracted by  \aginal  incision  by 
Gruzdews.  d. 

Secondary  operation  later  by 
Gruzdews,  and  forceps  found,  d. 

Ten  anil  a  half  years  later,  .second- 
ary ot)eration.  Forceps  per- 
forating   bowel.     Reported     by 

Stewart,  d. 


Result. 


7 
Death. 
Death. 


Death. 
Recovery 


Recovery 

? 
Death. 

Death. 


Recovery 
? 


? 
? 

Recovery 

Death. 

7 

Recovery 
Recovery 

Death. 
Recovery 

Recovery 

Recovery 
Recovery 

Recovery 

? 
Recovery 


REPORTED  CASES  OF  A  FOREIGN  BODY  LOST  IX  THE  ABDO.MIXAL  CAVITY.  941 

Abdominal  Section.     Sponges  and  Other  Articles  Left. 


No. 

214 

1906 

215 

1906 

216 

1906 

217 

1907 

218 

1907 

219 

1907 

220 

1907 

221 

1907 

222 

1907 

Operator* 


Character  of 
Operation. 


Article  Lo.st. 


Dollinger. 


Kuestner. 


Paris  surgeon. 


Sarcoma  of  ab- 
I     dominal  wall. 


Artery  forceps. 

Forceps. 
-Artery  forceps. 
Forceps. 


ICyst  of  pancreas.    Forceps. 


Ovarian  car- 
cinoma. 


Forceps. 
Forceps. 

Piece  of  an  instru- 
ment . 

Pair  of  spec- 
tacles. 


When  uri'!  H'^ 


Result. 


Six  years  later,  ileath  from  intes- 
tinal necrosis.  Forceps  found 
at  autopsy  within  bowels.  Re-i 
ported  by  LeGondre.  d.  ' 

Doyen  did  a  secondary  operation, 
and  found  forcep.;  within  in- 
testine.    Resection,  d. 

Four  months  I'.cer,  secondary  oper- 
ation by  Ward  for  ileus.  For- 
ceps found.  I 

Nearly  three  years  later  (after  two 
succe.ssful   pregnancies)     trouble 
from    forceps,     Operation. 
Death.     Lawsuit,  d. 

Six  weeks  later,  forceps  appeared 
at  angle  of  scar  and  was  ex- 
tracted, d. 

Found  at  autopsy.  Death  soon 
after  operation,  of  shock,  a 

Found  at  autopsy.  Death  after 
si.x  days,  of  ileus  and  peritonitis. 
d. 

-Details  not  given,  except  that 
piece  was  left  in  abdomen  at 
operation.     Criminal      trial,  d. 

Three  operations — in  .\merica, 
Germany,  France.  Frenchmani 
found  spectacles  in  abdomen. 
German  was  sued  for  damages  d. 


Death. 

•> 

? 
Death. 

Recovery 

Death. 
Death. 

Death. 

Recovery 


V.\Gix.\L  Operation'3.     Spoxges  axd  Other  Articles  Left. 


223 

224 
225 

1886 
1886 
1897 

Veit. 

Veit. 

Friend  of  H.  C. 
Coe. 

Vaginal  hysterec- 
tomy. 

Vaginal  hysterec- 
tomy. 

Vaginal  hysterec- 
tomy. 

Rubber  drain. 
Rubber  drain. 
Gauze  sponge. 

226 

1898 

Eriach. 

Vag.  operation 

for  fibroid. 

lodoform-gauze 
pack. 

227 
228 

1898 
1898 

Boldt. 
Rydygier. 

Vag.  drainage 
after  abdom. 
hysterectomy. 

Vaginal  hysterec- 
tomy 

Gauze  drain,  in- 
serted third 
day. 

Sponge. 

229 
2.30 

1899 
1899 

Meinert . 

Pel\ic  tuberculo- 
sis. 
.\dnexal  trouble. 

lodoform-gauze 

strip. 
Compress. 

231 

1899 

Schramm. 

Pyosalpinx. 

Tampon. 

232 

1900 

Hillmann. 

Pyosalpinx. 

Gauze  sponge. 

233 

1901 

? 

Pelvic  inflamma- 
tion. 

Sponge. 

234 
2.35 
236 
237 

1901 
1901 
1901 
1902 

Pryor. 

Assistant  to 

Pryor. 
.\ssistant  to 
Pryor. 

Vaginal  opera- 
tion. 
Vag.  operation. 

Vag.  operation. 

Uterine  tumor. 

Gauze. 
Gauze. 
Gauze. 
Tampon. 

238 
239 

1906 
1907 

Brothers. 
MacLaren.- 

Vaginal  hysterec- 
tomy. 

Pelvic  suppura- 
tion. 

Gauze  drain. 

lodoform-gauze 
strip. 

240 

1908 

Cal.nann. 

Vaginal  hysterec- 
tomy. 

Sponge,  slipped 
from  holder. 

Four  months  later,   drain  passed  [Recovery 
per  rectum^,  d.  j 

Later  expelled  from  the  bladder. {Recovery 
Details  not  given,  d.  > 

Two    days    later,    on    removing  ? 

clamps,  one  was  found  to  be  a 
sponge-holder  minus  the  sponge. 
Laparotomy,  found  sponge  un- 
der liver,  a. 

'Nine   days   later,    strip   found   in'Recovery 
vaginal   abscess.     Nine    months 
later,     another    strip    removed 
from  bladder,   c. 

Drain     forgotten.     Two     months  Recovery 
later  the  gauze  was  passed  per 
rectum,  a.  ! 

'Seven    weeks    later,    sponge    was  Death. 
discharged   from    vaginal   sinus. 
Patient  finally  died  of  p.vemia. 

Five  months  later,  extracted  from  Recovery 
vaginal  sinus,  a. 

One  year  later,  extracted  from  a  Recovery 
vaginal  sinus.     Cited  by  Mein-j 
ert.  a.  \ 

Ten  weeks  later,  tampon  came  out  Recovery 
while  patient  was  dancing,  c. 

Found    later    in    bladder,    accom-  Recoverv 
panied  by  violent  cystitis,  c. 

Later    secondary    operation     (ah-  Recovery 
dominal    section)     and     sponge 
found  in   pehis,    by   L.    Frank. 


b.c. 


Cited  by  W.  R. 


Cited  by  Pry- 
Cited  by  Pry- 


Details  not  given. 

Pr.vor.  b.  c. 
Details  not  given. 

or.  b  c. 
Details  not  given. 

or.  b.  c. 
Four  months  later,   tampon   wa.s{ Recovery 

extracted     per     vaginam.     Re-! 

ported  by  Gudbrod.    (/. 
Several    months   later,    drain    was  Recovery 

extracted  through  vasinal  sinus. 
Two  months  later,  the  patient  ex-  Recovery 

traded    a    twelve-inch    strip    of 

gauze  from  vasrina.  \ 

Extensive  palpation  per  vaginam,         ? 

extending  to  liver  and  kidneys. | 

Not  found.     Remo\ed  later  by, 

laparotom.v.  I 


a.  Cited  by  Neugebauer,  1900.  c.  Cited  by  Neusebauer,  1904. 

b.  ,A.dditional  cases,  cited  by  Schachner,  1901.  d.  Cited  by  Neugebauer.  1907. 
*Supposed  to  be  the  operator.     In  some  cases  the  record  is  not  entirely  clear  on  this  point. 


942  INVASION  OF  THE  PERITONEAL  CAVITY 

References  for  all  the  cases  cited,  and  also  other  items  of  importance  in 
connection  Avith  this  subject,  are  given  in  the  original  article.*  In  a  few 
cases  reports  obtained  from  different  sources  were  contradictory,  making  it 
difficult  to  determine  positively  certain  details  Avhere  the  original  report  was 
not  accessible.  Since  making  this  list  many  other  cases  have  been  brought 
to  my  notice,  but  it  is  not  necessary  to  include  them.  My  object  is  not  to 
make  a  complete  list,  but  simply  to  present  actual  cases  in  such  number  and 
variety  that  operators  will  be  led  to  pause  and  think  on  this  subject. 

VAGINAL  SECTION. 

Vaginal  section  is  incision  through  the  vaginal  wall  into  the  peritoneal 
cavity.  If  the  entrance  is  made  behind  the  cervix,  it  is  known  as  "posterior" 
vaginal  section.  If  the  opening  is  made  in  front  of  the  cervix,  it  is  known 
as  "anterior"  vaginal  section. 

In  some  cases  of  pelvic  disease  it  is  better  to  enter  the  peritoneal  cavity 
from  below — i.  e.,  by  vaginal  section ;  while  in  other  cases  it  is  better  to  enter 
from  above — i.  e,,  by  abdominal  section. 

ADVANTAGES 

Of  Vaginal  Section. 

The  advantages  of  Vaginal  Section,  in  suitable  cases,  are  as  follows : 

1.  Less  danger.  There  is  less  exposure  and  handling  of  the  intestines  and 
peritoneum.  In  vaginal  section  the  manipulations  are  nearly  all  in  the  pelvic 
cavity,  while  in  abdominal  section  the  central  portion  of  the  great  peritoneal 
sac  is  invaded;  theerfore,  in  vaginal  section  there  is  less  shock  and  less 
danger  of  general  peritonitis.  Again,  if  infection  should  develop  after  vaginal 
section,  it  is  very  likely  to  be  "walled  off"  from  the  general  peritoneal  cavity 
and  to  cause  simply  local  suppuration,  whereas  when  infection  appears  after 
abdominal  section  it  is  very  likely  to  take  the  form  of  an  acute  general 
peritonitis. 

2.  Evacuation  of  pus  without  contamination  of  peritoneal  surfaces.  This 
is  one  of  the  strongest  points  in  favor  of  vaginal  section  in  suitable  cases. 
As  a  rule,  when  there  is  a  large  collection  of  pus  that  can  be  reached  from 
below,  it  should  be  evacuated  that  way.  This  is  particularly  important  if 
the  pus  be  of  recent  origin.  In  such  a  case  it  is  very  important  to  prevent 
soiling  of  the  peritoneal  surfaces  with  this  infectious  fluid.  This  is  accom- 
plished by  opening  from  below. 

Again,  in  many  eases  of  pelvic  suppuration  the  pelvic  cavity,  containing 
the  abscess,  is  entirely  shut  off  from  the  general  peritoneal  cavity  by  a  wall 
or  roof  of  inflammatory    exudate,  which    binds  together    the  upper    pelvic 


♦Abdominal  Surgery  Without  Detached  Pads  or  Sponges;  A  Practical  Method  of  using  Gauze-strip.s  so  as  to 
Eliminate  the  Possibility  of  Any  Gauze  Being  Left  in  the  Abdomen.  By  H.  S.  Crossen,  M.  D. — Ayncrican 
Journal  of  Obstetrics,  vol.  LIX,  p.  58. 


VAGINAL  SECTION  943 

structiil'es.    When  operating  from  l)elo\v  we  work  heneatli   this  roof,   wliicli 
protects  tlie  general  peritoneal  cavity  from  contamination. 

3.  l^etter  drainage.  In  vaginal  section  the  opening  is  made  at  the  lowest 
part  of  the  pelvic  cavity — the  best  place  for  drainage. 

4.  Quicker  convalescence.  There  is  less  disturbance  of  the  intra-a])dominal 
structures.  Also,  the  wound  is  smaller,  better  protected  and  supported  by 
surrounding  parts,  and  is  not  so  likely  to  be  followed  by  hernia. 

5.  No  visible  scar.  This  is  of  some  importance.  A  long  scar  marking  the 
site  of  a  former  opening  into  one's  interior  is  not  particularly  pleasant  for  the 
patient  to  contemplate.  It  is  an  ever-present  reminder  of  the  disease  that 
Avas  present  and  of  the  operation.  '  It  is  well  to  avoid  making  such  a  scar 
in  cases  wliere  other  metliods  are  just  as  good. 

6.  Vaginal  section  combines  easily  with  certain  plastic  operations,  which 
are  sometimes  indicated  at  the  same  time. 

DISADVANTAGES. 

The  disadvantages  of  vaginal  section  are : 

1.  Lack  of  room  in  the  operative  field.  The  manipulations  are  cramped  and 
are  carried  out  with  less  certainty  of  accomplishing  the  desired  result. 

2.  Imperfect  exploration  of  pelvis  and  lower  abdomen.  The  pelvic  struc- 
■  ures  are  harder  to  reach  and  the  lower  abdominal  structures  (appendix,  etc.) 
can  not  be  satisfactorily  reached  at  all.  And  of  the  structures  reached,  the 
determination  of  their  condition  must  be  usually  made  a^:-.ost  altogether 
through  the  sense  of  touch,  for  the  structures  can  be  only  imperfectly  ex- 
posed to  sight. 

3.  Remnants  remain.  Where  the  adhesions  are  extensive  there  is  likely 
to  be  imperfect  work  unless  the  uterus  is  removed,  and  in  many  cases  it  is  not 
advisable  to  remove  the  uterus. 

4.  There  is  not  so  good  a  chance  to  determine  whether  or  not  the  conditions 
are  favorable  for  conservative  work  on  the  ovaries  or  tubes,  and  the  work 
itself,  when  indicated,  can  not  as  a  rule  be  so  satisfactorily  executed. 

5.  Appendix  affections  can  not  be  satisfactorily  handled.  The  appendix 
is  diseased  and  requires  removal  in  a  considerable  proportion  of  patients 
with  pelvic  disease. 

Selection  of  Cases. 

The  operative  cases  in  which  I  consider  the  vaginal  operation  preferable  to 
the  abdominal  are : 

1.  Acute  infection  in  the  pelvis  that  has  not  yet  spread  to  the  general 
peritoneum.  This  acute  severe  pelvic  peritonitis  is  seen  principally  in  cases 
of  sepsis  following  labor  or  abortion.  If  general  peritonitis  is  present,  abdom- 
inal section  is  preferable. 

2.  A  collection  of  pus  low  in  the  pelvis  within  easy  reach  of  the  fingers, 


944  INVASION  OF   THE  PERITONEAL  CAVITY 

particularly  if  there  is  a  probability  that  the  general  peritoneal  cavity  is  well 
walled  off  above. 

3.  For  exploration  of  the  pelvis  in  certain  doubtful  cases  when  it  is  evident 
that  all  the  information  required  can  be  determined  from  below. 

The  operative  cases  in  which  I  consider  abdominal  section  preferable  to 
vaginal  section  include : 

1.  Chronic  inflammatory  lesions,  with  or  without  a  collection  of  pus. 

2.  Cases  of  adherent  retrodisplacement  of  the  uterus. 

3.  Cases  in  which  conservative  work  on  ovaries  or  tubes  is  probably  re- 
quired. 

4.  Ovarian  and  broad  ligament  and  uterine  tumors  (except  certain  fibroids 
that  can  be  satisfactorily  removed  from  below). 

5.  Extra  uterine  pregnancy  (except  where  all  that  remains  is  a  walled-off 
hematocele). 

6.  Cases  complicated  with,  or  probably  complicated  with,  appendix  trouble. 

7.  Obscure  cases,  requiring  thorough  examination  of  the  pelvis  and  lower 
abdomen. 

PREPARATIONS 

For  Vaginal  Section. 

The  preparations  for  vaginal  section  are  practically  the  same  as  for  ab- 
dominal section,  except  that,  in  the  preparation  of  the  operative  iield,  the  ex- 
ternal genitals  and  the  vagina  are  prepared  instead  of  the  abdomen. 

The  patient  receives  an  antiseptic  douche  one  to  three  times  daily,  depend- 
ing upon  the  amount  and  character  of  the  discharge.  The  afternoon  or  even- 
ing before  the  operation  the  external  genitals  and  adjacent  surfaces  are 
shaved  and  then  carefully  scrubbed  with  green  soap  and  warm  water,  using 
cotton-balls  or  a  soft  brush.  The  vagina  also  is  cleansed  with  cotton-balls 
held  in  the  forceps.  This  cleansing  should  be  done  gently,  so  as  not  to  abrade 
the  vaginal  surface  and  thus  invite  infection  at  points  in  the  operative  field. 
No  alcohol  nor  ether  is  used  here,  as  it  Avould  cause  too  much  irritation. 
After  the  careful  cleansing  with  soap,  the  soap  is  cleared  away  with  sterile 
water  and  the  vagina  and  external  genitals  are  cleansed  with  a  bichloride 
solnlion  (1-2000).  After  the  cleansing  the  parts  are  covered  with  bichloride 
pack  (cotton  wrung  out  of  1-5000  bichloride  solution).  Some  prefer  to  pack 
the  vagina  at  tliis  time  with  antiseptic  gau/o,  the  packing  to  remain  in  place 
until  llic  ])Mli<'ii1  is  anesthetized  for  the  operation.  If  there  is  much  discliarge, 
however,  the  packing  liohls  tlie  discliarge  in  the  vagina,  where  it  decomposes 
more  or  less ;  consefjuently,  in  sucli  cases  the  packing  is  not  advisal)le. 

Tn  certain  complicated  cases  and  in  doubtful  cases  tlie  alidomen  also  should 
be  prepared,  as  it  may  be  necessary  to  employ  abdomiiinl  siH'tion  in  order  to 
deal  satisfactorily  with  the  conditions  found. 

After  the  patient  is  under  the  anesthetic  the  external  genitals  and  vagina 


CONSERVATIVE  SURGERY  945 

are  scrubbed  thoronglily,  first  with  the  soap  solution  and  later  with  tlie  bichlo- 
ride solution.  This  cleausius"  under  anesthesia  (Figs.  574,  575)  is  the  most 
important  step  in  the  antiseptic  preparation,  for  it  can  be  made  so  much 
more  thorough  than  before  anesthesia  Avhen  there  is  likely  to  be  pain  and  re- 
sistance. 

STEPS 

In  Vaginal  Section. 
The  steps  in  the  operation  are  essentially  the  same  as  for  abdominal  section, 
changing  the  field  from  the  abdominal  surface  to  the  depths  of  the  vagina. 
The  steps  are : 

1.  Anesthesia. 

2.  Exposure  of  operative  field  by  suitable  retractors. 

3.  Incision  and  entrance  into  the  peritoneal  cavity. 

4.  Exploration. 

5.  Correction  of  pathological  condition. 

6.  Restoration  of  structures  to  approximately  normal  relations. 

7.  Closure  of  incision  or  drainage,  as  thought  preferable  in  that  particular 
case. 

8.  Dressing. 

CONSERVATIVE  SURGERY 

of  the  Ovaries,  Tubes,  Uterus. 

By  the  term  "conservative  surgery"  is  meant  the  conserving  or  saving  of 
undiseased  portions  of  ovaries  and  tubes,  or  of  portions  that  are  somewhat 
affected,  but  not  enough  to  threaten  serious  trouble  should  they  be  left.  A 
"conservative  operation, ",_  then,  is  an  operation  that  saves  an  organ  or  part 
of  an  organ  that  would  otherwise  (by  the  regular  radical  operation)  be  wholly 
removed.  Conservative  surgery  of  the  ovaries  and  tubes  is  of  rather  recent 
development,  and  in  order  to  bring  it  before  you  in  its  proper  relation  I  shall 
recall  briefly  the  steps  preceding  it. 

Before  the  eighteenth  century,  operation  for  the  removal  of  ovarian  tumors 
had  been  suggested  by  a  number  of  physicians,  but  it  had  never  been  put  into 
practice.  Later,  the  celebrated  John  Hunter  and  the  equally  celebrated  John 
Bell  both  advocated  the  operation,  but  neither  of  them  ventured  to  perform  it. 

The  first  ovariotomy  in  the  world  was  performed  by  Ephraim  McDowell, 
a  native  of  Virginia,  practicing  in  Kentucky.  McDowell  had  attended  the 
lectures  of  John  Bell  in  Edinburg  in  1749 ;  and  was  convinced  of  the  correct- 
ness of  his  teacher's  views  in  regard  to  the  removal  of  ovarian  tumors.  He 
returned  to  Kentucky  and  practiced  his  profession  without  special  incident 
until  1808,  when  he  was  confronted  bj^  a  case  of  ovarian  tumor  requiring  oper- 
ation. After  giving  the  matter  careful  consideration  and  making  full  ex- 
planation to  the  patient,  he  performed  the  operation,  and  the  patient  re- 
covered.    From  that  time  the  practice  gradually  spread  over  the  civilized 


946 


INVASION  OF  THE  PERITONEAL  CAVITY 


world,  and  after  half  a  century  ovariotomy  became  comparatively  frequent. 
The  ovaries  were  removed,  not  only  for  tumors,  but  for  all  sorts  of  ovarian 
diseases,  from  the  most  serious  to  the  most  trivial.  In  fact,  it  became  quite 
common,  later,  to  remove  practically  normal  ovaries  for  various  nervous  dis- 
turbances which  it  was  thought  might  be  due  to  them  (Battey's  operation). 


After  a  time,  however,  it  began  to  dawn  upon  the  profession  that  the 
ovaries  had  another  function  than  ovulation,  and  that  when  the  ovaries  were 
removed  the  patient  was  deprived,  not  only  of  ovulation,  but  also  of  some 
factor  which  has  a  marked  influence  on  the  general  health.  Gradually  the 
trophic  function  of  the  ovary,  explained  when  speaking  of  the  physiology  of 
the  ovary,  was  worked  out.  From  the  facts  thus  far  established  we  know 
that,  aside  from  the  consideration  of  ovulation  or  pregnancy,  an  ovary  should 


Fig.  728.  Conservative  Surgery  of  Ovary  and  Tube.  Excision  of  damaged  portion  of  tube,  showing  how 
the  end  of  the  stump  is  spUt  and  sewed  open.  Excision  of  cyst  from  ovary,  witli  preservation  of  the  unaffected 
portion  of  the  organ. 

be  preserved  wherever  possible  on  account  of  the  influence  it  exerts  over  the 
patient's  health,  particularly  over  her  nervous  system. 

The  objects  for  Avhich  conservatism  is  thus  practiced  in  pelvic  surgery 
are  three : 

1.  Preservation  of  the  possibility  of  pregnancy.  To  make  pregnancy  possible, 
there  must  be  one  ovary,  or  a  functionating  piece  of  one  ovary,  and  a  patient 
tube.  The  patent  tube  may  be  on  the  same  side  as  the  ovary  or  on  the  oppo- 
site side.  It  may  be  a  normal  tube  or  it  may  be  simply  the  stump  of  a  tube, 
the  remainder  of  the  tube  having  been  removed  on  account  of  some  disease 
(Fig.  728). 

Under  all  these  circumstances  pregnancy  is  possible  and  has  taken  .place 
in  a  number  of  instances.  Of  course,  it  is  not  as  likely  to  take  place  as  in  a 
normal  individual,  but  still  the  patient  has  a  chance  of  becoming  pregnant. 


CONSERVATIVE  SURGERY  947 

Another  point,  sometimes  overlooked,  is  that,  even  though  no  pregnancy- 
results  from  these  efforts  at  conservatism,  the  simple  fact  that  the  patient 
may  become  pregnant — that  pregnancy  is  still  possible — conduces  much  to  her 
peace  of  mind. 

2.  Anotlier  effect  sought  by  conservative  pelvic  surgery  is  continuation  of 
menstruation.  Even  though  the  hope  of  pregnancy  must  be  sacrificed  on  ac- 
count of  disease  necessitating  the  complete  removal  of  both  tubes,  if  an  ovary 
or  functionating  piece  of  an  ovary  can  be  left  in  the  pelvis  with  the  uterus, 
menstruation  continues,  though  pregnancy  is  impossible. 

3.  Still  another  effect  sought  by  this  conservative  surgery  is  the  continua- 
tion of  the  trophic  influence  of  the  ovary.  When  the  uterus  must  be  removed, 
pregnancy  and  menstruation  are  of  course  no  longer  possible.  However,  if 
an  ovary  or  a  functionating  piece  of  an  ovary  can  be  saved,  the  trophic  in- 
fluence of  the  ovary  is  preserved,  provided  that  the  retained  portion  of  the 
ovary  continues  its  function — i.  e.,  continues  to  form  ova  and  corpora  lutea. 

This  latter  fact  must  be  kept  in  mind.  The  mere  leaving  of  a  portion  of  the 
ovary  does  not  insure  a  continuation  of  menstruation  or  of  the  trophic  in- 
fluence. To  produce  the  desired  result,  the  portion  of  ovary  left  must  con- 
tinue to  functionate.  If  its  nutrition  is  so  interfered  with  that  ovulation  does 
not  continue,  it  is  just  the  same  as  though  no  ovarian  tissue  had  been  left. 
Some  time  ago  there  came  to  me  a  woman  who  had  been  operated  on  in  a 
distant  city.  The  operator  had  told  her  that  she  would  menstruate,  as  part 
of  one  ovary  had  been  left  in  place.  Menstruation,  however,  ceased  entirely 
after  the  operation,  and  when  I  saw  the  patient  she  was  suffering  from  the 
symptoms  of  the  artificial  menopause.  She  was  inclined  to  think  that  both 
ovaries  had  been  completely  removed  and  to  blame  the  operator  for  "deceiv- 
ing" her.  It  was  evidently,  however,  one  of  those  cases  in  which  the  portion 
of  ovary  preserved  had  not  survived  in  condition  to  continue  its  functions, 
and  the  patient's  confidence  in  her  former  physician  was  restored  by  this 
explanation. 

4.  Another  form  of  conservative  work  is  the  preservation  of  a  part  of  the 
corpus  uteri  in  certain  fibroid  cases  ordinarily  subjected  to  supravaginal 
hysterectomy.  Instead  of  removing  all  of  the  uterus  except  the  cervix, 
the  amputation  of  the  affected  portion  is  made  so  as  to  preserve  the  lower 
part  of  the  corpus.  Again,  the  uterus  may  be  split  in  the  median  line,  the 
tumor  and  affected  portion  removed  and  the  remaining  lateral  portions,  with 
as  much  endometrium  as  possible,  preserved  and  sutured  together.  In  this 
way  the  preservation  of  menstruation,  which  is  an  important  matter  in  young 
women,  may  be  attained  in  certain  cases. 

Conservative  pelvic  surgery  in  its  various  forms  is  still  in  the  developmental 
stage.  As  more  and  more  of  this  conservative  work  is  done  and  remote  re- 
sults recorded,  we  shall  be  able  to  determine  more  accurately  its  limitations, 
and  to  say  in  just  what  conditions  it  is  advisable  and  in  what  conditions  not 
advisable. 


948 


CHAPTER  XVI. 

AFTER-TREATMENT  IN  OPERATIVE  CASES. 

AFTER=TREATMENT   IN  ABDOMINAL  SECTION. 

The  details  of  the  care  of  a  patient  after  abdominal  section  may  be  divided 
into  (A)  the  regular  after-treatment  and  (B)  the  care  in  special  conditions. 

(A.)    REGULAR  AFTER-TREATMENT. 

First  Day.  During  the  operation  the  bed  which  the  patient  is  to  occupy 
should  be  warmed  with  hot-water  bottles  placed  under  the  blankets.  When 
the  patient  is  placed  in  bed  the  hot  water  bottles  are  distributed  about  her, 
to  maintain  the  heat  and  diminish  shock.  Care  should  be  taken  that  there 
is  no  leakage  from  any  bottle,  and  that  a  thick  blanket  is  everywhere  between 
the  hot  bottles  and  the  patient.  Much  discomfort  and  even  serious  injury 
may  follow  a  burn  from  a  hot-water  bottle,  caused  by  the  bursting  of  a  bot- 
tle or  leakage  from  a  bottle,  or  a  too  thin  protective  covering  between  the  bot- 
tle and  the  patient.  In  several  instances  legal  complications  have  resulted, 
involving  the  nurse  or  the  hospital,  or  the  physician. 

The  patient's  head  should  be  low  (no  pillow  under  it)  until  ^he  has  re- 
covered from  the  anesthetic.  Keep  the  patient  quiet  and  let  her  sleep  as  long 
as  she  will  from  the  anesthesia.  If  the  patient  vomits,  she  should  be  turned 
well  over  on  the  side  to  cause  the  vomited  material  to  run  out  of  the  throat, 
that  there  may  be  no  chance  of  its  getting  into  the  larynx  and  choking  her. 
Death  may  occur  from  this  cause.  To  diminish  the  thirst,  swab  the  "interior 
of  the  mouth  frequently  (when  the  patient  is  awake)  with  cold  water,  either 
plain  or  acidulated  with  a  few  drops  of  vinegar  or  lemon  juice. 
The  orders  for  the  first  day  are  usually  about  as  follows: 

If  in  much  pain,  give  codeine  phosphate  Va  gr.  to  %  gr.  hypod.,  and  repeat  after 

two  hours  as  necessary  to  give  rest. 
If  vomiting,  turn  well  on  one  side. 
May  have  water  as  soon  as  she  wishes  it— hot  or  cold,  as  best  retained,  half  an 

ounce  every  fifteen  minutes  when  desired,  unless  vomiting  persistently. 
Catheterize   only    if '  necessary.     When   bladder   fills,   employ    usual    expedients   to 
assist   urination    (propping    up    in   bed,    warm    water    to    genitals,    pressure    on 
bladder,  etc.). 

It  is  not  necessary  ordinarily  for  the  patient  to  be  kept  strictly  on  her  back. 
After  a  few  hours,  if  very  tired  of  the  one  position,  she  may  be  propped 
partly  to  one  side  or  the  other  occasionally.  But  she  must  not  be  allowed  to 
develop  that  restlessness  that  insists  on  constantly  changing  from  one  side 


REGULAR  AFTER-TREATMENT  949 

to  the  other  in  an  endeavor  to  tind  a  comfortable  position.  No  position  is  very 
comfortable  under  the  circumstances  and  the  too  frequent  changing  in- 
creases the  discomfort. 

The  patient  should  be  quieted  as  much  as  possible  without  medicine,  in  or- 
der that  the  administration  of  sedatives  may  be  avoided  or  kept  within  small 
amount.  The  nurse  can  do  much,  by  arranging  the  patient  comfortably  in 
bed  and  directing  her  frequently  to  keep  the  eyes  closed  and  to  nap  as 
much  as  possible.  If  there  is  such  severe  pain  that  the  codeine  does  not  give 
rest,  morphia,  in  1-6  gr.  doses,  may  be  given,  but  that  is  rarely  necessary. 
If  preferred,  the  sedative  may  be  given  by  suppositories,  but  its  effect  is  not 
so  prompt  and  cannot  be  so  accurately  graduated. 

As  a  rule  I  prefer  to  let  the  patient  have  Avater  in  small  doses  as  soon  as  she 
wishes  it.  It  diminishes  the  thirst  and  helps  to  supply  the  system  Avith  needed 
fluid.  Occasional  vomiting  does  no  harm ;  rather  it  is  beneficial  in  that  it 
helps  to  clear  out  the  ether-saturated  mucus,  the  retention  of  which  increases 
stomach  irritation  and  disturbance.  If  there  is  persistent  vomiting,  and 
especially  if  there  is  persistent  epigastric  pain,  a  stomach  tube  should  be  in- 
troduced and  the  stomach  washed  out  with  a  quart  of  normal  saline  solution. 
This  stomach  w^ashing  (lavage)  has  come  to  be  recognized  as  a  most  important 
measure  in  post-operative  treatment.  It  is  the  only  effective  treatment  for 
the  serious  complication  of  acute  dilatation  of  the  stomach  (page  961),  and 
in  any  case  of  persistent  stomach  irritation  it  adds  much  to  the  patient's 
comfort  by  clearing  out  the  irritating  material. 

If  the  patient  can  not  take  water  by  mouth,  the  thirst  may  be  diminished 
by  saline  solution  per  rectum  by  the  drop  method  (proctoclysis).  If  the  pa- 
tient is  in  shock,  start  the.  proctoclysis  and  employ  the  other  measures  for 
that  condition   (page  959). 

Second  Day.  During  the  second  day  the  orders  previously  given  are  con- 
tinued unless  there  is  some  special  reason  for  modifying  them.  The  patient 
may  take  water  more  freely,  and  the  liquid  nourishment  is  now  begun  and 
gradually  increased  as  the  stomach  wall  bear  it.  For  this  purpose  peptonized 
milk  may  be  used,  or  milk  and  lime-water  (half  and  half),  or  albumen  water 
or  beef  tea — one  or  two  ounces  about  every  two  hours,  hot  or  cold  as  best 
retained. 

If  the  patient  has  to  be  catheterized,  it  is  well  to  give  some  reliable  urinary 
antiseptic  to  diminish  the  danger  of  cystitis.  If  gas  in  the  intestines  is 
troublesome,  a  rectal  tube  may  be  introduced.  If  the  operation  was  an 
emergency  one,  where  there  was  no  opportunity  for  preliminary  preparation 
of  the  intestinal  tract,  it  may  be  advisable  to  secure  a  bowel-movement 
within  the  second  twenty-four  hours,  in  which  ease  the  calomel  is  now  bc^- 
gun.    Ordinarily,  however,  that  is  preferably  postponed  until  the  tliird  day. 

Third  Day.  At  the  beginning  of  the  third  day  start  the  patient  on  the 
purgative  regimen,  indicated  below,  that  a  bowel  movement  may  be  secured 
some  time  during  this  tAventy-four  hours.  If  the  quantity  of  urine  is  good, 
the  frequency  and  duration  of  the  proctoclysis  (if  it  is  being  used)  may  be 
reduced. 


950  AFTER-TREATMENT  IN  ABDOMINAL  SECTION 

The  orders  for  the  third  day  are  usually  about  as  follows : 

Calomel  %  gr.  every  half  hour  till  eight  doses  are  taken.  Four  hours  after  last 
dose  of  calomel  give  a  high  enema  of  magnesium  sulphate  (1  oz.),  glycerine 
(2  oz.)   and  water   (4  oz.).     This  is  to  be  retained  twenty  minutes  if  possible. 

If  there  is  not  a  satisfactory  bowel  movement  from  this  enema,  give  the  patient 
a  teaspoonful  of  Rochelle  salt  every  two  hours  till  three  doses  are  taken,  and 
four  hours  after  the  last  dose  repeat  the  magnesium  sulphate  enema. 

Continue  the  codeine  if  necessary  to  give  rest. 

Urotropin  5  gr.  in  two  ounces  of  water  every  eight  hours. 

Fourth  Day.  Ordinarily  by  this  time  one  or  two  good  bowel  movements 
have  been  secured,  and  the  patient  has  become  fairly  comfortable.  If  the 
kidneys  are  secreting  well,  the  proctoclysis  may  be  stopped.  All  medicines  may 
now  be  given  by  mouth.  The  patient  may  be  propped  up  as  necessary,  to  aid 
in  urination  if  she  is  not  already  urinating.  Some  semi-solid  and  solid  arti- 
cles of  diet  (custards,  breakfast  foods,  toast,  crackers,  bread,  etc.)  may  be 
allowed.  As  a  rule,  no  sedative  is  now  necessary,  except  an  occasional  dose 
of  sodium  bromide  when  the  patient  is  particularly  restless  at  night.  It  is 
well  to  start  the  patient  on  some  good  iron  tonic,  for  these  patients  are 
usually  anemic.  Tincture  of  the  chloride  of  iron,  with  care  in  giving,  is  ex- 
cellent. If  preferred,  some  one  of  the  numerous  organic  iron  preparations 
may  be  used.  If  adhesive  strips  have  been  put  on  at  the  first  dressing,  re- 
move them  now,  so  that  the  skin  will  be  in  good  condition  for  the  other  strips 
to  be  put  on  when  the  sutures  are  removed. 

The  orders  given  at  this  time  may  serve  as  standing  orders,  to  be  continued 
as  long  as  the  patient  is  in  the  hospital,  except  when  modified  for  some 
special  indications.    They  are  about  as  follows : 

Strychnia  sulphate,  1-40  gr.  in  a  capsule,  three  times  daily,  after  meals. 

Tincture  ferri  chloridi,  10  drops  in  a  capsule,  three  times  daily,  after  meals. 

Light  diet,  with  extras.  Push  the  nourishment.  Give  an  abundance  of  water 
and  of  liquid  nourishment.  Articles  from  the  regular  diet  may  be  added  as 
desired. 

Urotropin,  5  gr.  in  half  a  glass  of  water,  twice  daily.  Laxative  pill  (aloin,  bella- 
donna, strychnia  and  cascara)  one  each  night,  unless  bowel  movements  are 
too   frequent. 

Give  an  enema  when  no  bowel  movement  during  day. 

Subsequent  Orders.  It  is  well  to  continue  the  urinary  antiseptic  for  a 
week  after  the  urine  is  passed  spontaneously.  The  diet  is  gradually  in- 
creased until  the  patient  is  taking  regular  diet  with  extras.  She  should  con- 
tinue to  take  liquid  nourishment  between  meals. 

If  during  convalescence  the  patient  does  not  take  and  digest  sufficient 
food,  the  digestive  powers  may  be  increased  by  massage,  salt  rubs,  passive 
movements  and  resisted  movements,  judiciously  administered  by  a  com- 
petent nurse.  The  careful  carrying  out  of  the  regular  nursing  given  bed 
patients  (including  the  daily  morning  bath  and  evening  alcohol  rub)  is  also 
an  important  factor  in  causing  the  patient  to  be  comfortable  and  to  rest  well 


REMOVING  THE  SUTURES 


951 


at  night,  and  to  digest  her  food  promptly.    If  there  is  any  decided  digestive 
disturbance,  some  remedy  for  that  should  of  course  be  given. 

Removing  the  Sutures.  Unless  there  is  some  indication  of  irritation  in 
the  wound,  the  dressing  is  not  to  be  disturbed  for  ten  days  .  Then  it  is  taken 
off  and  the  sutures  removed.  The  Avound  is  now  healed.  The  vicinity  of  the 
wound  is  dusted  freely  with  boric  acid  powder,  a  smooth  piece  of  gauze  (sev- 
eral thicknesses)  is  laid  over  the  scar  (Fig.  718),  and  the  abdomen  is  strapped 
with  strij)s  of  two-inch  adhesive  plaster  (Fig.  729)  in  such  a  way  as  to  take 
the  strain  from  tlie  newly  healed  wound.    Four  to  six  strips  are  put  on  (Fig. 


Fig.  729.     Strapping  the  Abdomen  after  removing  the  sutures. 


730),  so  as  to  give  firm  support.    Then  a  piece  of  cotton  is  placed  over  all 
and  the  binder  reapplied. 

The  adhesive  strips  are  usually  left  undisturbed  for  about  a  week.  If  it  is 
desired  to  look  at  the  wound  area,  because  of  irritation  along  the  suture 
tracts  or  for  other  reason,  the  adhesive  plaster  is  cut  along  the  edges  of  the 
gauze  (Fig.  730)  and  the  gauze  removed  so  that  the  scar  and  vicinity  are 
exposed  (Fig.  731).  After  the  required  treatment,  gauze  is  again  applied 
and  then  new  plaster  put  on,  the  ends  of  the  new  plaster  adhering  to  the 
old  plaster  at  each  side.    This  permits  inspection  of  the  wound  area  as  often 


952 


AFTER-TREATMENT  IN  ABDOMINAL  SECTION 


as  desired  Avithout  the  discomfort  of  repeated  removal  of  plaster  from  the 
skin. 

Ordinarily,  however,  the  adhesive  strips  need  not  be  disturbed  for  a  week. 
In  the  meantime  a  strong,  light-weight  abdominal  supporter  is  fitted  to  the 
patient.  It  is  well  to  leave  the  adhesive  strips  on  until  the  patient  reaches 
home,  as  thev  serve  as  an  additional  protection  during  the  extra  exertion 
of  the  trip.  After  the  patient  reaches  home  and  the  abdominal  supporter 
has  become  comfortably  adjusted,  the  adhesive  strips  are  taken  off.  The 
supporter  is  to  be  worn  for  about  three  months,  but  only  when  the  patient 
is  up  and  about.  It  may  be  taken  off  at  night.  Some  authorities  recommend 
that  no   abdominal  supporter  or  binder  be  worn.    But  while  most   patients 


Fig.  730.    Cutting  the  Plaster,  so  as  to  inspect  the  wound  and  change  the  gauze  without  remo\ing  the  plaster 
from  tlie  skin. 


get  along  very  well  without  it,  I  feel  that  it  is  a  precaution  which  it  is  well 
to  employ.  It  is  of  decided  benefit  in  some  cases  (where  the  abdominal  wall 
is  lax  and  protuberant)  ;  it  adds  to  the  patient's  comfort  in  most  cases,  it 
reminds  the  patient  of-  the  necessity  of  avoiding  over-exertion  in  all  cases, 
and  it  does  no  harm  in  any  case  if  waist  constriction  be  avoided. 

Sitting"  Up,  Walking".  T'nless  there  is  some  special  reason  for  hurrying 
the  patient  to  t]i(_'  sitting  posture,  she  should  be  allowed  to  remain  quiet  and 
in  the  recumbent  posture  for  the  first  few  days.  After  the  bowels  liave 
moved  well,  I  encourage  the  patient  to  move  about  in  the  bed  and  to  be 
propped  up  as  much  as  she  likes — more  and  more  each  day — so  that  by  the 


SITTING  UP— WALKING 


953 


end  of  the  first  week  she  is  ready  to  sit  out  of  bed  and  begin  walking.  The 
advantages  of  this  early  moving  about  in  the  bed  and  early  getting  up  are 
better  circulation  (less  "bed-weakness"),  and  consequently  better  repair  of 
wounds,  better  digestion  and  quicker  restoration  to  normal  condition. 

It  is  not  advisable,  however,  to  get  the  patient  up  too  early,  while  nature 
is  still  fully  occupied  with  the  acute  repair  work  of  the  first  few  days.  The 
feeling  of  the  patient  is,  as  a  rule,  the  best  guide  as  to  w^hen  to  begin  activity. 
I  am  convinced  that  the  plan  just  described  is  decidedly  preferal)le  to  the 
"hurry  up"  method  of  getting  the  patient  out  of  bed  in  one  or  two  days, 
which  was  recently  so  popular  with  some.  In  cases  where  I  think  the  patient 
will  be  benefited  by  further  rest,    I  do    not  hesitate  to    keep  her   in   bed  ten 


Fig.  731.     Method  of  Exposing  the  Wound  as  often  as  necessary  for  change  of  dressing,  without  causing 
the  patient  the  discomfort  of  repeated  removal  of  plaster  from  the  skin.     The  new  plaster  is  put  over  the  old. 


days  or  two  weeks,  or  even  longer.  In  many  instances  the  patient  is  greatly 
debilitated  and  literally  "worn  out"  by  chronic  sepsis  or  by  months  of  suf- 
fering and  ill-health,  or  by  heroic  work  for  her  children  in  spite  of  failing 
strength.  In  all  these  cases  the  enforced  rest  in  bed  may  be  an  important 
aid  in  restoring  the  patient's  health. 

After  the  patient  has  returned  to  her  home,  the  tonic  medicines  and  regimen 
should  be  kept  up  for  three  to  six  months,  as  necessary,  to  put  the  patient 
in  first-class  general  health. 


954 


AFTER-TREATMENT  IN  ABDOMINAL  SECTION 


(B.)    SPECIAL  CONDITIONS. 

1.  Drainage  Cases.  When  a  glass  tube  is  left  extending  into  the  pelvis 
for  drainage,  a  large  piece  of  sterile  sheet-rubber  is  usually  slipped  over 
the  end  of  the  tube  (Fig.  732),  to  keep  the  fluid  that  comes  out  of  the  tube 


Fig.  732.  Dressing  the  Drainage  Tube.  The 
piece  of  sheet -rubber  punctured  and  slipped  over 
the  end  of  the  tube. 


Fig.  733.  Dressing  the  Drainage  Tube.  The 
gauze  wick  and  applicator  for  emptying  the 
tube.  After  the  tube  is  emptied,  a  gauze  wick  is 
left  in  it  to  assist  drainage. 


Fig.  7?A.  Dressing  the  Drainage  Tube.  Gauze 
pieces  arranged  about  the  end  of  the  tube,  to 
absorb  the  discharge. 


Fig.  735.  Dressing  the  Drainage  Tube.  The 
sheet -rubber  folded  over,  to  inclose  the  gauze 
about  the  end  of  the  tube  and  thus  protect  the 
general  dressing. 


from  soiling  the  gauze  on  the  abdominal  wound.  A  small  wick  of  twisted 
gauze  (Fig.  733)  is  then  passed  to  the  bottom  of  the  wound  to  aid  in  the 
drainage.  This  twisted  wick  should  be  small  enough  to  leave  plenty  of  room 
around  it  inside  the  tube  to  permit  the  discharge  to  come  out.    Some  pieces 


CARE    OF    DRAINAGE  CASES 


955 


of  gauze  are  now  placed  over  the  end  of  the  tube  (Fig.  734)  and  the  piece 
of  sheet-rubber  is  folded  over  the  gauze  from  all  sides  (Fig.  735).  The  whole 
is  then  covered  with  a  large  piece  of  sterile  cotton  and  the  binder  applied, 
taking  care  to  avoid  pressing  on  the  tube.  This  is  the  technique  ordinarily 
emploj^ed  in  the  dressing  at  the  time  of  the  operation. 

The  frequency  with  which  the  drainage  tube  must  be  dressed  varies  with 
the  amount  of  drainage  fluid.  In  chronic  cases,  where  the  pelvis  is  left  fairly 
dry,  the  amount  of  fluid  is  usually  small.  It  is  well  to  dress  the  tube  within 
three  to  six  hours,  or  before  if  there  is  a  probability  of  much  oozing  or  secre- 
tion.   The  frequency  of  the  subsequent  dressing  is  regulated  by  the  amount 


Fig.  736.     Dressing  the  Drainage  Tube.     Articles  required — applicator,  scissors  and  pair  of  rubber  gloves. 


of  fluid  found.  The  idea  is  to  change  the  dressing  before  all  the  gauze  con- 
fined in  the  rubber-dam  becomes  filled  with  absorbed  fluid.  Usually  every 
eight  to  twelve  hours  is  sufficient  for  the  first  two  days  and  after  that  once 
daily. 

In  cleansing  and  dressing  the  tube  the  strictest  asepsis  must  be  observed. 
The  instruments  needed  are  simply  a  long  probe  or  applicator,  for  pushing 
the  gauze  wick  to  the  bottom  of  the  tube,  and  a  scissors  for  cutting  the  gauze. 
These  instruments  should  be  boiled,  and  in  addition  to  the  ordinary  disin- 
fection of  the  hands  it  is  well  to  wear  sterilized  rubber  gloves  (Fig.  736). 
After  the  preparation  of  the  instruments  and  of  the  physician's  hands,  the 
binder  and  outer  part  of  the  dressing  is  removed  by  the  nurse,  thus  expos- 


956 


AFTER-TREATMENT  IN  ABDOMINAL  SECTION 


ing  the  sterile  sheet-rubber.  The  physician  then  unfolds  the  sheet-rubber  and 
removes  the  gauze  therein  and  also  the  saturated  gauze  wick  in  the  tube. 
Another  gauze  wick  is  then  twisted,  taking  care  to  remove  all  loose  ravel- 
ings.  The  end  of  this  sterile  wick  is  then  pushed  to  the  bottom  of  the  tube 
and  left  there  for  a  minute  to  absorb  the  discharge.   It  is  then  removed  and  a 


Fig.  737.     Syringe  and  part  of  a  catheter,  for  removing  large  amount  of  fluid  from  drainage  tube. 


fresh  one  introduced.  This  process  is  repeated  until  all  the  fluid  in  the  tube 
is  removed.  A  fresh  wick  is  then  introduced  and  gauze  is  placed  about  the 
end  of  the  tube,  and  the  sheet-rubber  folded  over  as  before.  The  inner  sur- 
face of  the  rubber-sheeting  should  l)e  cleansed  with  some  reliable  antiseptic 
solution  (e.  g.,  ])ichloride,  1-2000)  and  the  interior  of  the  tube  may  be 
cleansed  with  a  gauze-wick  wrung  out  of  the  same  solution.  Also,  the  'tube 
should  be  raised  slightly   and  rotated   once   daily,   iu  order  to   prevent   in- 


CARE   OF  DRAINAGE  CASES 


957 


jurious  pressure  on  tlie  rectum  (which  laiglit  cause  perforating  ulceration) 
and  to  prevent  stopping-up  of  the  drainage  holes  by  omentum  or  bowel,  or 
exudate. 

The  tube  is  removed  "wheu  the  collection  of  tluid  in  the  pelvis  ceases — that 
is,  in  two  to  five  days.  In  suppurative  cases  the  secretion  of  course  keeps 
up  indeiinitely.  In  such  a  case  the  tube  is  left  in  until  all  acute  threatening 
symptoms  have  disappeared  and  until  a  good  wall  has  formed  about  the  tube 
tract,  shutting  it  off  from  the  general  peritoneal  cavity.  It  may  as  a  rule  be 
removed  in  four  to  six  days,  and  a  small  ru])V)er  tul)e  or  piece  of  gauze  in- 


Fig.  738.  Elevation  of  the  Upper  Part  of  the  Body,  to  aid  Drainage  toward  the  pel\is.  This  simple  eleva- 
tion of  the  head  of  the  bed  is  employed  immediately  after  operation,  and  in  other  cases  where  the  patient  is 
too  weak  to  be  placed  in  the  "half-sitting"  or  regular  Fowler  posture.  The  head  of  the  bed  is  raised  about 
twenty-four  inches. 

serted  into  the  tract  to  keep  the  outer  end  open  until  it  closes  from  tlie  l)ot- 
tom.  The  treatment  of  such  a  tract  is  to  keep  it  clean  by  cleansing  (daily 
or  less  frequently,  as  needed)  with  hydrogen  peroxide,  keeping  the  outer 
end  open  as  mentioned,  and  protecting  it  from  secondary  infection  by  an 
antiseptic  dressing.  It  is  well  to  keep  some  antiseptic  drying  powder  (e.  g., 
boric  acid)  dusted  freely  on  the  wound  about  the  drainage  tube. 

In  acute  cases,  where  there  is  virulent  infection  and  free  secretion,  the  tube 
must  be  cleansed  very  frequently — as  often  as  every  t^vo  or  three  hours  at 
first.    In  these  cases,  where  the  fluid  is  abundant,  the  removal  of  it  from  the 


958 


ABDOMINAL  SECTION 


tube  is  preferably  aeeomplislied  -vvitli  a  syringe.  A  very  convenient  arrange- 
ment for  this  purpose  is  the  ordinary  hard-rubber  syringe  with  a  soft-rubber 
catheter  attached.  It  is  more  convenient  to  handle  when  only  two-thirds  of 
a  catheter  is  used,  as  shown  in  Fig.  737.  In  the  very  acute  cases,  where 
drainage  in  various  directions  is  required  and  it  is  necessary  to  leave  the 
wound  partly  open,  the  whole  dressing  soon  becomes  soiled  with  the  dis- 
charge and  consequently  must  be  changed  frequently.  In  fact,  in  some  of 
these  cases  it  is  advisable  to  employ  warm  moist  dressings  (wrung  out  of 
normal  saline  solution  or  boric  acid  solution,  3  per  cent)  all  over  the  abdo- 
men and  wound,  the  moist  dressing  to  be  changed  every  few  hours,  or  as 
often  as  it  absorbs  a  considerable  amount  of  the  septic  discharge. 


Fig.  739.     Elevation  of  the  Upper  Part  of  the  Body,  to  aid  Drainage  toward  the  pelvis  (Fowler  posture). 


When  rubber  tubing  is  used  for  drainage,  it  may  be  used  alone  or  with 
gauze  around  the  tube  or  as  the  "split -tube  with  gauze."  In  the  latter  a 
piece  of  large  rubber  tubing .  is  split  longitudinally  and  a  small  wick  of 
twisted  gauze  laid  inside,  but  the  gauze  wick  must  be  small  enough  to  per- 
mit the  free  escape  of  fluid  through  the  tube.  Rubber-tube  drains  are  left 
in  until  the  necessity  for  drainage  has  disappeared  and  the  drainage  tract 
is  largely  closed  from  the  bottom.  Where  the  rubber  tube  is  of  large  size, 
it  is  removed  after  a  few  days  and  a  smaller  size  introduced. 

When  gauze  is  used  for  drainage,  alone  or  with  rubber  tubing,  it  is  re- 
moved usually  in  two  to  four  days. 


TREATMENT  OF  SHOCK 


959 


In  all  drainage  cases,  except  where  the  patient  is  in  severe  shock,  the 
upper  part  of  the  body  should  be  raised  higher  than  the  pelvis,  so  as  to 
cause  all  septic  fluid  in  the  peritoneal  cavity  to  gravitate  to  the  pelvis,  where 
it  is  removed  through  the  drainage  tube.  Immediately  after  the  operation 
raise  the  head  of  the  bed  about  two  feet,  as  shown  in  Fig.  738.  After  the 
patient  has  recovered  from  the  anesthetic  she  may  be  propped  up  in  the  half- 
sitting  posture  (Fowler  posture),  as  shown  in  Fig.  739. 

In  acute  septic  cases  normal  saline  solution  should  be  used  freely  per  rec- 
tum, as  described  on  page  722. 

2.  Uterine  Replacement  Cases.  The  principal  special  points  in  the  care 
of  the  patient  after  any  operation  for  fastening  the  uterus  and  adnexa  for- 


Fig.  740.     Elevation  of  the  Lower  Part  of  the  Body,  for  the  treatment  of  Shock.     The  foot  of  the  bed  is 
raised  about  twenty-four  inches. 

ward,  is  to  see  that  the  bladder  is  not  allowed  to  fill  sufficiently  to  force 
the  uterus  backward  again  in  the  first  few  days  following  operation.  If  the 
patient  can  not  urinate,  she  should  be  catheterized  often  enough  to  prevent 
injurious  distention. 

3.  Severe  Shock.  When  the  patient  is  in  severe  shock,  the  head  should  be 
lowered  by  the  elevation  of  the  foot  of  the  bed  about  two  feet,  as  shoAvn  in 
Fig.  740,  except  in  those  eases  where  there  is  danger  of  spreading  pus  from 
the  pehds  to  the  upper  part  of  the  uncontaminated  peritoneal  cavity. 

Give  the  patient  digitalin  1-50  gr.   every  two    hours    and    strychnia  sul- 


950  AFTER-TREATMENT  IN  ABDOMINAL  SECTION 

pliate  1-40  gr.  every  four  hours  until  reaction  comes  on.  Still  more  im- 
portant is  the  free  use  of  normal  saline  solution  by  proctoclysis.  If  the  shock 
is  extreme,  saline  solution  may  be  given  also  subcutaneously,  one  or  two 
pints  under  the  skin  of  the  chest  on  one  or  both  sides.'  If  a  very  large  cpian- 
tity  of  blood  has  been  lost  and  the  pulse  is  thready  and  almost  gone,  a  pint 
to  a  pint  and  a  half  of  saline  solution  may  be  given  intravenously.  The  use 
of  oxygen  is  an  additional  measure  of  value  in  eases  where  respiration  is 
defective. 

The  hot  water  bottles  must  be  renewed  as  necessary  to  keep  the  patient 
warm,  and  the  proctoclysis  and  other  treatment  should  be  given  in  such  a 
way  as  to  avoid  chilling  of  the  surface. 

4.  Internal  Hemorrhage.  A  serious  internal  hemorrhage  is  indicated  by 
rapid  weakening  of  the  pulse,  an  increase  of  pain  in  the  abdomen  and  sub- 
normal temperature.  It  is  rare  after  the  first  twelve  hoiu's,  and  usually 
comes  within  the  first  six  hours.  If  there  is  a  drain  through  the  abdominal 
incision  or  into  the  vagina,  there  will  be  a  free  flow  of  bloody  serum,  or,  if 
it  is  a  tube  drain,  of  blood  itself. 

The  treatment  of  a  slight  hemorrhage  is  (a)  to  elevate  the  pelvis  by  rais- 
ing the  foot  of  the  bed  (Fig.  7-10),  (b)  to  put  an  ice-bag  on  the  pelvis  out- 
side the  dressing,  (c)  to  keep  the  patient  perfectly  cpiiet  on  her  back,  and 
(d)  to  give  a  sedative  (codeine)  if  necessary  to  secure  rest.  Discontinue 
the  normal  saline  enemata,  as  the  pelvic  disturbance  occasioned  thereby  may 
increase  the  hemorrhage  or  start  it  after  it  had  once  ceased.  Do  not  give  any 
stimulants  or  employ  any  measure  that  will  increase  the  blood  pressure. 
The  hope  is  that,  as  the  blood-pressure  is  low,  the  bleeding  will  cease  for  a 
few  hours — long  enough  to  permit  effective  clotting  to  take  place  in  the 
oozing  area.  In  twenty-four  hours  such  clots  become  so  firm  that  a  renewal 
of  the  bleeding  is  not  probable. 

"When  the  hemorrhage  is  severe,  the  abdomen  should  be  promptly  re- 
opened (if  the  patient  is  seen  in  time)  and  the  bleeding  vessel  caught. 

5.  Persistent  Vomiting.  To  make  the  nausea  and  vomiting  as  slight  as 
possible,  the  patient's  head  should  be  low  (no  pillow)  for  several  hours 
after  anesthesia.  For  the  first  day  the  patient  should  be  kept  perfectly  quiet, 
with  the  eyes  closed  most  of  the  time,  so  as  to  nap  as  much  as  possible.  The 
nausea  is  increased  by  talking  or  by  even  looking  about.  If  a  visitor  is 
allowed,  it  should  be  for  only  a  few  minutes  and  there  should  be  but  little 
talking.  When  water  is  begun,  it  is  preferable  usually  to  give  hot  water, 
in  tablespoonful  doses  and  frequently,  though  some  patients  retain  cold 
water  very  well  from  the  first.  When  the  nausea  and  vomiting  is  such  that 
the  patient  can  not  rest,  give  codeine  phosphate,  i/o  to  %  gr.  hypodermically, 
and  repeat  after  three  hours,  as  necessary  to  give  rest. 

The  most  effective  measure  for  overcoming  vomiting,  persistent  nausea, 
and  stomach  distress  generally  is  washing  out  of  tlie  stomach  with  normal 
saline  solution,  as  described  on  page  720.  After  the  bowels  are  well  opened 
the  vomiting  usually  ceases  unless  there  is  some  serious  complication,  such 


TREATMENT  OF  INTESTINAL  PARALYSIS  961 

as   beginning  peritonitis   or  intestinal   obstruction,   both   of  which   are   men- 
tioned later. 

6.  Acute  Dilatation  of  Stomach.  This  is  a  serious  complication  that  may- 
develop  any  time  after  operation,  but  especially  within  the  first  sixty  hours. 
The  patient  complains  of  persistent  pain  in  the  epigastric  region,  and  this 
region  becomes  more  or  less  distended.  The  pulse  becomes  rapid  and  w^eak 
without  apparent  cause.  There  is  usually  nausea  and  vomiting,  but  the  most 
constant  and  characteristic  signs  are  the  persistent  epigastric  pain  and  the 
failing  pulse.  The  anatomical  change  is  over-distention  of  the  stomach  with 
gas,  due  to  different  causes  in  different  cases.  In  the  majority  of  cases  it  is 
probably  due  to  some  displacement  of  the  stomach,  with  kinking  and  o])struc- 
tion  at  the  pylorus.  As  the  gas  can  not  escape,  its  continued  accumulation 
becomes  a  serious  matter,  and  in  several  instances  death  has  resulted  from 
over-distention  of  the  stomach  caused  thereby. 

The  treatment  for  this  condition  is  prompt  introduction  of  the  stomach 
tube,  to  permit  the  gas  to  escape,  and  irrigation  of  the  stomacli  with  normal 
saline  solution  to  remove  all  decomposing  material  and  prevent  reaccumula- 
tion  of  the  gas.  This  complication  should  be  watched  for  and  recognized,  and 
the  stomach  tube  used  before  it  reaches  a  serious  stage.  If  the  trouble  re- 
curs, several  stomach-washings  may  be  required.  It  is  well  also  to  vary  the 
patient's  position,  so  as  to  overcome  displacement  of  the  stomach  aiid  drag- 
ging on  its  supports.  In  some  cases  it  has  been  thought  that  the  Fowler 
posture  was  a  factor  in  the  development  of  this  condition. 

7.  Kidney  Insufficiency.  This  is  easier  prevented  than  treated  after  it 
once  develops.  The  preventive  measure  is  to  make  sure  that  the  kidneys  are 
doing  their  work  well  before  operation.  The  treatment  for  kidne.y  insuffi- 
ciency after  operation  consists  in  the  free  administration  of  normal  saline 
solution  by  proctoclysis,  in  elimination  by  means  of  free  bowel-movements, 
and  sweat  packs  and  such  other  measures  as  are  used  for  the  regular  treat- 
ment of  uremia.  In  urgent  cases  the  normal  saline  solution  may  be  given 
subcutaneously  or  even  intravenously. 

8.  Constipation  and  Intestinal  Paralysis.  When  the  purgative  measures 
given  under  the  regular  after-treatment  (page  950)  fail  to  cause  bowel 
movement,  the  loss  of  function  may  be  due  simply  to  temporary  paralysis  of 
the  bowel  or  to  intestinal  obstruction,  or  to  beginning  peritonitis.  Unless 
there  are  decided  evidences  of  intestinal  obstruction  or  peritonitis,  it  is  to  be 
assumed  that  the  trouble  is  temporary  intestinal  paralysis,  and  treatment 
for  the  same  is  begun.  The  treatment  consists  in  giving  strychnia,  in  giv- 
ing repeated  doses  of  purgatives,  such  as  compound  cathartic  pills  or  mag- 
nesium sulphate  by  mouth,  and  in  administering  enemata  that  tend  to  stimu- 
late the  bowels  to  action.  A  tablespoonful  of  turpentine  may  be  added  to 
the  magnesium-sulphate  enema  already  mentioned.  Or  the  patient  may  be 
given  a  high  enema  of  half  an  ounce  each  of  ox-gall  and  turpentine  in  a  pint 
of  water,  to  be  retained  as  long  as  possible.  Eserin  salicylate  has  seemed  to 
assist  in  stimulating  intestinal  peristalsis  in  some  cases — 1-80  gr.  hypod.,  and 
repeat  after  four  hours  if  no  effect. 


962  AFTER-TREATMENT  IN  ABDOMINAL  SECTION 

9.  Intestinal  Obstruction.  This  is  indicated  by  the  combination  of  per- 
sistent vomiting,  absence  of  bowel  movement  in  spite  of  the  use  of  the  purga- 
tive measures  already  mentioned,  severe  cramp-like  pains  in  the  abdomen  re- 
curring every  few  minutes,  a  serious  rise  in  the  pulse  rate,  and  the  absence 
of  fever,  such  as  would  be  caused  by  peritonitis  of  sufficient  severity  to  give 
rise  to  the  other  symptoms.  Later  there  is  fecal  vomiting.  Such  a  combina- 
tion of  symptoms  calls  for  immediate  reopening  of  the  abdomen,  and  relief 
of  the  obstruction.  Unless  this  is  carried  out  promptly,  there  will  develop  a 
peritonitis  which,  in  combination  with  the  obstructive  trouble,  is  very  likely 
to  prove  fatal  in  spite  of  later  operation. 

10.  Peritonitis.  This  is  indicated  by  the  combination  of  symptoms  consist- 
ing of  fever  (beginning  or  increasing  after  the  second  day),  persistent  vomit- 
ing (extending  into  the  fourth  and  fifth  days),  serious  increase  in  the  pulse 
rate,  steady  pain  in  the  abdomen  (without  the  cramp-like  pains  of  intestinal 
obstruction),  and  an  increasing  tenderness  in  the  lower  abdomen,  which 
gradually  spreads  to  the  upper  abdomen.  The  intestinal  tract  is  usually  slug- 
gish (partial  intestinal  paralysis),  but  there  is  not  the  complete  absence  of 
bowel  movement,  such  as  is  seen  in  intestinal  obstruction. 

A  rise  of  temperature  within  the  first  twenty-four  hours  after  operation  is 
not  of  serious  significance.  Not  infrequently  in  extensive  operations,  involv- 
ing large  peritoneal  or  connective-tissue  surfaces,  there  is  a  sharp  rise  of  tem- 
perature (up  to  102°  or  103°),  coming  on  within  twenty-four  hours  and  sub- 
siding the  second  or  third  day  without  further  disturbance.  In  the  absence 
of  a  more  definite  explanation,  this  "aseptic  rise  of  temperature"  is  said 
to  be  due  to  the  "absorption  of  blood-ferment."  But  when  there  is  a  rising 
temperature  after  the  second  day,  it  is  indicative  of  some  unusual  dis- 
turbance, and  when  the  combination  of  symptoms  above  mentioned  is  present 
the  diagnosis  of  peritonitis  is  clear. 

The  treatment  of  peritonitis  following  operation  is  the  same  as  for  peri- 
tonitis without  operation.  This  has  already  been  described  under  Acute  Pel- 
vic Inflammation  (page  717). 

11.  Local  Suppuration.  This  is  indicated  by  fever,  coming  on  after  the 
sixth  day,  and  a  moderate  increase  in  the  pulse  rate  and  localized  pain.  If 
the  suppuration  is  deep  in  the  pelvis,  the  patient  complains  of  deep-seated 
pain  and  usually  of  backache  or  of  pain  extending  down  one  thigh.  If  the 
inflammatory  focus  is  situated  in  the  back  part  of  the  pelvis,  bowel  movement 
()r  the  giving  or  an  enema  causes  pain.  Vaginal  examination  shows  a  boggy 
mass,  which  is  very  tender.  The  treatment  for  such  local  inflammation  deep 
in  the  pelvis  is  to  secure  good  bowel  movement,  to  make  the  patient  com- 
fortable, to  i::crease  tissue  resistance,  and  to  await  resolution  or  al)scess 
fonuation.  Yvhou  fluctuation  can  be  detected  by  vaginal  examination,  open 
and  dr;iin  tlio  al)scess  per  vaginnm.  Exceptionally,  it  may  be  advisal)lo  to 
open  into  fi  solid  mass  Cinflanniintory  focns  witlioi;!  fluctuation)  or  to  open 
into  the  ciil-de-sae  for  general  pelvic  draiiiagc. 

When  the  suppuration  is  in  the  abdominal  incision,   there  is  increasing 


TREATMENT   OF   PHLEBITIS  963 

pain  along  the  course  of  the  incision.  This  calls  for  removal  of  the  dressing 
and  inspection  of  the  wound.  Inflaniniation  there  is  indicated  by  the  cardinal 
signs  (pain,  heat,  redness  and  swelling),  localized  at  some  part  of  the  incis- 
ion, or  extending  all  along  it.  If  the  disturbance  is  slight,  a  hot  moist  anti- 
septic dressing,  changed  every  twenty-four  hours,  may  ])e  sufficient.  If  there 
is  a  pronounced  cellulitis  at  some  point,  that  portion  of  the  wound  should 
be  opened  superficially  and  a  gauze  or  tube  drain  put  in  and  the  hot  moist 
dres.sing  applied.  If  drainage  of  the  infected  area  can  be  satisfactorily  ef- 
fected without  removing  the  tension  sutures,  that  is  preferable.  In  some  in- 
stances the  inflammation  is  confined  to  the  subcutaneous  tissue  and  no  dis- 
turbance of  the  deep  buried  sutures  is  necessary.  The  important  point,  how- 
ever, is  to  secure  free  drainage  of  the  infected  area  and  prevent  serious  ab- 
sorption. If  the  whole  wound  is  infected,  it  must  all  be  drained.  In  such  a  case 
the  whole  Avound  (except  the  peritoneum)  is  likely  to  open.  As  soon  as 
serious  absorption  has  ceased,  the  sides  of  the  wound  are  brought  together 
by  strapping  with  adhesive  strips,  the  wound  being  exposed  and  cleansed 
every  day  or  two  (depending  on  the  amount  of  discharge)  with  hydrogen 
peroxide.  Later,  if  thought  preferable,  the  granulating  surfaces  may  be 
freshened  by  curetting  and  then  brought  together  by  sutures,  with  the  idea  of 
securing  secondary  union. 

12.  Phlebitis.  This  seldom  occurs  now%  since  patients  are  gotten  out  of  bed 
early.  When  it  does  appear,  it  is  usually  in  about  the  third  week,  when  the 
patient  has  passed  the  time  for  the  ordinary  operative  complications  and  is 
congratulating  herself  that  she  will  soon  be  entirely  well. 

She  complains  of  pain  in  the  groin  and  upper  part  of  the  thigh  on  one 
side,  and  the  temperature  gradually  rises  to  102°  or  103°.  There  may  or  may 
not  be  swelling  of  the  foot  and  leg,  but  there  is  always  tenderness  on 
pressure  over  the  femoral  vessels  just  below  Poupart's  ligament.  This  ten- 
derness may,  in  some  cases,  be  traced  a  considerable  distance  down  the  thigh, 
and  also  up  along  the  iliac  vessels. 

The  treatment  of  phlebitis  is  immediate  bandaging  of  the  leg  and  thigh 
(from  toes  up),  elevation  of  the  leg  in  a  comfortable  position  on  pillows, 
and  the  maintenance  of  this  position  and  of  the  dorsal  posture  for  several 
days.  In  mild  cases  the  measures  mentioned  usually  relieve  tlie  sponlaneous 
pain,  but  in  the  severe  cases  sedatives  may  be  necessary  for  a  time  to  give  rest. 

It  Avill  be  necessary  to  maintain  this  position  most  of  the  time  for  a  week 
or  more,  depending  on  the  severity  of  the  trouble  and  the  rapidity  of  the  im- 
provement. When  the  above  treatment  is  carried  out  promptly  and  persist- 
ently, serious  trouble  seldom  results.  If  the  patient  is  permitted  to  use  tlie 
leg,  the  suffering  is  increased  and  the  disability  prolonged,  and  there  is  dan- 
ger of  serious  embolism  by  particles  detached  from  the  thrombosed  area  in 
the  vein  and  carried  to  the  brain  or  heart  or  lungs.  On  account  of  the  danger 
of  detaching  emboli,  no  massage  or  rubbing  of  the  involved  area  is.  permissi- 
ble until  sometime  after  all  acute  symptoms  have  subsided. 

Getting  patients  out  of  bed  early  (at  the  end  of  a  week)  has  almost  elimi- 


964  AFTER-TREATMENT  IN  ABDOMINAL  SECTION 

nated  this  complieation.  I  have  not  had  a  case  now  for  two  years,  while  under 
the  old  regimen  of  keeping  the  patients  in  bed  three  weeks  it  was  rather 
frequent,  occurring  in  about  two  per  cent,  of  the  abdominal  operative  cases. 

13.  Pain  During  Convalescence.  Aside  from  the  conditions  already  men- 
tioned and  the  natural  soreness  of  the  recently  disturbed  structures,  pain 
during  convalescence  is  usually  due  to  gastric  or  intestinal  indigestion,  with 
gas  formation  and  resulting  painful  intestinal  peristalsis.  The  treatment 
for  this  condition  is  to  remove  the  irritating  material  from  the  intestinal 
tract  by  an  enema  and  laxatives,  and,  if  necessary,  administer  some  remedy 
for  the  gastric  or  intestinal  indigestion.  Of  course,  operated  patients  are 
subject  to  neuralgic  and  neurasthenic  pains  the  same  as  other  individuals, 
and  these  are  likely  to  be  more  pronounced  at  the  menstrual  time. 

An  abdominal  operation  often  causes  the  menstrual  flow  to  appear  ahead 
of  time.  Not  infrequently  there  is  also  a  slight  bloody  flow  from  the  uterus, 
without  any  relation  to  menstruation,  within  a  few  days  after  the  operation. 
Such  need  occasion  no  alarm,  as  it  disappears  in  a  short  time. 

14.  Subsequent  Disturbances.  As  the  patient  begins  to  walk  about,  there 
may  be  more  or  less  soreness  in  the  pelvis  for  some  time,  until  the  hyperemia 
of  the  healing  tissues  has  disappeared  and  the  new  connective  tissue  is  firm. 

In  drainage  cases  a  sinus  sometimes  persists.  The  persistence  of  such  a 
sinus  may  be  due  to  sloughing  tissue  or  to  a  ligature.  In  the  case  of  a  cat- 
gut ligature  or  sloughing  tissue,  the  troul-lesome  material  will  usually  dis- 
integrate and  come  away  in  the  course  of  some  Aveeks.  The  sinus-track,  in 
the  meantime,  should  be  kept  clean  by  freciuent  cleansing  with  hydrogen 
peroxide — every  day  or  two,  depending  on  the  amount  of  discharge.  The 
patient  can  care  for  the  fistula  at  home  after  being  shown  how  to  apply  the 
peroxide  and  the  dressing. 

If  a  silk  ligature  is  at  the  bottom  of  the  sinus,  it  may  come  out  itself  after 
some  weeks  or  months,  or  it  may  have  to  be  taken  out.  Sometimes  it  may 
be  caught  up  by  "fishing"  with  a  silkworm-gut  loop  or  other  contrivance. 
Otherwise,  it  must  be  removed  by  operation.  A  rare  cause  of  persistent  fistula 
is  a  sponge  or  forceps  left  in  the  cavity. 

Occasionally  a  fistula  connected  with  the  bowel  follows  abdominal  sec- 
tion. Ordinarily  such  a  fistula  should  be  treated  by  a  simple  cleansing  for 
some  time,  for  in  a  considerable  portion  of  the  cases  it  will  heal  spontaneously 
Avithin  a  few  weeks.  If  it  persists  indetinitely,  it  requires  operative  treatment. 
Such  an  operation  should  not  be  undertalani  lightly,  for  it  may  prove  very  diffi- 
cult and  dangerous. 

A  hernia  in  the  scar  indicates  defective  healing  of  the  Avound.  This  is  usually 
due  to  the  necessity  for  drainage,  which  prevents  perfect  approximation  of 
the  sides  of  the  wound.  If  the  hernia  is  small,  it  may  in  some  cases  be  held 
l)ack  satisfactorily  by  an  abdominal  supporter.  If  large,  or  if  persistently 
troublesome  even  though  small,  it  requires  operative  treatment. 


AFTER-TREATMENT  IN  VAGINAL  OPERATIONS 


965 


AFTER=TREATMENT  IN  VAGINAL  OPERATIONS. 

The  general  after-treatment  of  vaginal  operations  is  practically  the  same  as 
for  abdominal  operations. 

Gauze  extending  from  the  vagina  into  the  peritoneal  cavity  is  removed 
usually  in  three  or  four  days.  After  removing  gauze,  if  there  is  much  of  a 
cavity,  it  is  advisable  to  replace  the  gauze  in  the  vaginal  incision,  to  keep  it 
open  until  the  cavity  is  nearly  closed  by  granulation.  In  the  case  of  an  a1)- 
scess  cavity,  a  rubber  tube,  arranged  as  previously  explained   (Fig.  687),  is 


/ 


^ 


m 


Fig.  741.     Cleansing  the  External  Genitals.     The  use  of  the  "Pitcher-douche." 


preferable.  After  the  gauze  is  left  out  of  the  vagina,  a  cleansing  douche  of 
normal  saline  solution  or  an  antiseptic  solution  is  given  once  or  twice  daily, 
depending  on  the  amount  of  discharge. 

After  a  vaginal  or  perineal  operation  the  vulva  and  adjacent  surfaces  must 
be  kept  covered  with  an  antiseptic  dressing,  the  same  as  any  other  wound 
region.  Here,  however,  on  account  of  the  necessity  of  evacuation  of  the  bowel 
and  bladder,  the  problem  of  wound  protection  is  more  complicated.  The 
dressing  must  be  changed  several  times  daily  and  with  each  change  of 
dressing  there  is  danger  of  contamination. 


966 


AFTER-TREATMENT  IN  VAGINAL  OPERATIONS 


When  it  is  necessary  to  change  the  dressing,  the  nurse  should  disinfect 
her  hands  and  then  cleanse  the  operative  field  with  an  antiseptic  solution 
(e.  g.,  bichloride  1-5000).  The  cleansing  may  be  conveniently  accomplished 
by  means  of  the  ''pitcher  douche"  (Fig.  741).  After  the  cleansing  a  fresh 
dressing  is  put  on  and  the  T-bandage  again  applied  (Fig.  742). 

If  the  patient  can  pass  the  urine,  she  should  ordinarily  be  permitted  to  do 


Fig.  742.     The  Vulvar  Dressing  Applied.     This  dressing  should  be  large  enough  to  co\er  all  the  adjacent 
surfaces,  including  the  pubic  hairy  region,  and  should  be  kept  spread  out  by  a  wde  T-bandagei 


so,  whatever  the  character  of  the  vaginal  work.  Catheterization  is  more  like- 
ly to  do  harm  than  urination,  especially  as  the  urine  remaining  on  the  gen- 
itals is  at  once  removed  by  the  cleansing  solution.  To  aid  spontaneous  urina- 
tion, patient  may  be  propped  up,  hot  packs  on  the  vulva  may  be  used,  and  also 
firm  pressure  over  the  bladder  as  the  patient  is  trying  to  urinate.  Hot 
douches  also  aid  some,  and  may  be  used  if  there  is  no  contraindication. 

,  In  many  cases,  however,  the  patient  cannot  urinate  at  first,  and  must  be 
cathetorized  for  two  or  three,  or  more,  days.  Catheterization  must  be  carried 
out  under  strict  antiseptic  precautions.     The  catheter  is  boiled,  the  nurse's 


CATHETERIZATION 


967 


Fig.  743.  Catheterization.  After  the  nurse  cleanses  the  vestibule  as  here  indicated,  the  labia  must  be  kept 
spread  apart  until  the  catheter  is  introduced.  When  the  labia  are  allowed  to  drop  back  over  the  meatus  after 
cleansing,  the  meatus  must  be  again  cleansed  with  the  antiseptic  solution  before  the  catheter  is  introduced. 


Fig.  744.  Catheterization.  After  the  catheter  is  boiled,  do  not  touch  the  point  with  the  fingers.  The 
catheter  is  grasped  well  back  from  the  point,  as  here  .shown,  and  the  point  is  introduced  into  the  urethra  without 
touching  the  labia  or  the  finger.s.     A  glass  catheter  or  a  soft  rubber  catheter  may  be  used,  as  preferrei. 


968  AFTER-TREATMENT  IN  VAGINAL  OPERATIONS 

hands  are  disinfected,  and  the  vestibule  and  meatus  of  the  patient  are  care- 
fully cleansed  with  an  antiseptic  solution.  After  the  labia  are  once  separat- 
ed and  the  vestibule  cleansed,  the  labia  must  be  kept  separated,  so  that  there 
is  no  recontamination  of  the  vicinity  of  the  meatus,  until  the  catheter  is  in- 
troduced (Figs.  743,  744).  Care  should  be  taken  to  avoid  touching  the  part 
of  the  catheter  which  enters  the  bladder.  The  catheter  should  be  grasped 
well  back  from  the  point,  as  shown  in  Fig.  744.  In  order  to  prevent  cystitis, 
it  is  well  to  give  the  patient  some  reliable  internal  urinary  antiseptic  while 
she  has  to  be  catheterized  and  for  several  days  after  the  urine'  is  passed 
spontaneously.  An  additional  precaution  is  to  have  the  bladder  irrigated 
with  3  per  cent,  boric  acid  solution  once  or  twice  daily  while  catheterization  is 
necessary. 

For  the  After-treatment  of  Pelvic  Abscess,  see  page  713. 

For  the  After-treatment  of  Perineorrhaphy,  see  page  493. 

For  the  After-treatment  of  Trachelorrhaphy,  see  page  556. 

For  the  After-treatment  of  Curetment,  see  page  582. 

The  After-treatment  of  Extraperitoneal  Shortening  of  Round  Ligaments  is 
practically  the  same  as  for  Abdominal  Section  with  the  special  points  for 
Retrodisplacement  cases,  except  that  there  are  two  wounds  and  they  are 
situated  laterally  and  do  not  require  particular  support  after  they  are  healed. 


9C9 


CHAPTER  XVII. 

MEDICO-LEGAL  POINTS  IN  GYNECOLOGY. 

There  are  various  conditions  connected  with  the  genital  organs  concerning 
whicli  the  physician  may  be  called  to  testify  in  court  or  to  give  a  written 
opinion. 

Such  testimony  is,  generally  speaking,  simply  the  recitation  of  facts  in 
anatomy,  pliysiology,  pathology,  symptomatology,  diagnosis,  treatment  and 
prognosis,  with  which  the  physician  is  necessarily  more  or  less  familiar  because 
of  his  daily  work.  But  there  are  certain  things,  of  little  or  no  value  in  the 
ordinary  diagnosis  and  treatment  of  diseases,  which  assume  much  importance 
when  the  case  comes  into  court.  So,  when  called  to  attend  a  case  in  -svhich 
there  is  any  probability  of  court  proceedings,  the  facts  that  are  of  medico- 
legal importance  should  be  given  considerable  attention. 

I  shall  point  out  some  of  these  facts  in  connection  with  certain  subjects  that 
frequently  find  their  way  into  court. 

RAPE. 

Rape  is  defined  as  "the  unlawful  carnal  knowledge  of  a  woman  without 
her  consent,"  and  again,  more  in  detail,  as  "sexual  intercourse  Avitli  a  woman 
effected  by  violence,  or  with  a  young  girl  by  abuse  of  her  ignorance." 

Medical  evidence  is  ordinarily  required  to  confirm  or  disprove  the  state- 
ment that  rape  has  taken  place.  False  accusations  of  rape  are  very  fre- 
quent. Taylor  states  that  for  one  real  rape  tried  in  the  courts  there  were, 
on  the  average,  twelve  pretended  cases.  Some  of  these  cases  of  false  accusa- 
tion are  founded  on  a  mistake,  as  may  happen  with  infants,  children  and  per- 
sons mentally  defective.  In  other  cases  the  accusations  are  made  willfully 
and  designedly  for  the  purpose  of  extortion  or  revenge,  or  from  other  ulterior 
motive.  In  some  instances  the  false  accusation  may  be  at  once  disproved  by 
medical  evidence,  though  it  has  happened  that  the  medical  man  has  been 
deceived  and  duped  by  designing  persons.  In  many  cases  in  adults  the 
medical  evidence  is  not  decisive,  and  the  truth  or  falsity  of  the  charge  must 
rest  almost  wholly  on  the  statements  of  the  prosecutrix  herself  along  with 
the  corroborating  circumstances. 

The  question  for  the  physician  to  decide  as  far  as  possible,  from  his  exam- 
ination, is  whether  or  not  sexual  intercourse  took  place,  or  was  attempted, 
at  approximately  the  time  indicated.  Subsidiary  information  may  be  re- 
quired— e.  g.,  as  to  whether  there  were  evidences  of  violence  elsewhere  on  tl>e 
body,  or  as  to  whether  intercourse  has  ever  taken  place  or  has  freciuently 


'970  MEDICO-LEGAL  POINTS  IN  GYNECOLOGY 

taken  place,  or  as  to  whether  death  was  caused  by  the  injuries  inflicted,  or 
as  to  whether  disease  was  communicated  at  the  time,  and,  if  so,  what  is  the 
nature  and  probable  outcome  of  such  disease.  On  all  such  points  the  physi- 
cian is  supposed  to  be  informed,  and  he  is  also  supposed  to  keep  such  record 
of  his  cases  as  Avill  enable  him  to  testify  with  certainty,  some  years  after- 
ward, concerning  his  findings  in  any  particular  case. 

For  the  consideration  of  the  medical  evidence  of  rape  it  is  convenient  to 
divide  the  case^  into  three  classes,  the  first  including  infants  and  children,  the 
second  including  young  unmarried  women  and  the  third  including  married 
women. 

There  are,  however,  certain  points  that  should  be  kept  in  mind  in  all  cases. 
"When  called  to  examine  or  treat  a  person  on  whom  rape  is  alleged  to  have 
been  committed,  notice  and  record,  as  soon  as  you  can  conveniently,  the  fol- 
lowing points,  for  you  are  likely  to  be  questioned  in  court  concerning  them. 

1.  The  precise  time  at  which  you  were  summoned,  the  exact  hour  and  date 
of  the  examination  and  the  place  of  the  examination.  It  is  important  in  some 
cases  to  know  whether  or  not  the  female,  alleged  assaulted,  took  the  earliest 
opportunity  to  complain.  Also,  the  exact  time  elapsing  between  the  alleged 
assault  and  the  examination  has  an  important  bearing  on  the  signs  found. 
The  place  of  the  examination  at  a  certain  time  may  be  important  as  showing 
the  truth  or  falsity  of  some  statement  of  the  defense  or  prosecution  regarding 
the  movements  of  the  female  shortly  after  the  time  of  the  alleged  assault. 

2.  Marks  of  violence  about  the  genitals. 

3.  Marks  of  violence  on  the  body  elsewhere  or  on  the  clothing  of  the  com- 
plainant. 

4.  Presence  of  stains  of  spermatic  fluid  or  of  blood  on  the  clothing.  When 
the  character  of  the  stain  is  not  clear,  make  a  microscopic  examination  of  the 
contaminating  material. 

5.  The  existence  of  disease  probably  conveyed  in  the  alleged  assault  (gon- 
orrhoea, syphilis,  chancroid). 

The  evidences  of  rape  will  vary  with  the  age  of  the  patient  and  other  cir- 
cumstances. 

It  may  be  stated  that,  to  establish  the  fact  of  rape,  it  is  not  necessary  to 
prove  penetration  into  the  vagina  by  the  male  organ.  It  has  been  decided 
that  if  the  evidence  shows  penetration  of  the  vulva  or  to  the  vulvar  cleft, 
that  is  sufficient — the  legal  establishment  of  the  crime  requiring  only  the  fact 
of  the  penetration,  the  degree  of  penetration  being  quite  immaterial.  Conse- 
quently, the  hymen  is  not  necessarily  ruptured,  even  in  cases  where  entrance 
of  the  male  organ  into  the  vagina  would  be  absolutely  impossible  without 
such  rupture.  "]\ledical  men  sometimes  have  fallen  into  error  on  this  point, 
considering  that,  when  the  hymen  was  entire,  rape  could  not  have  been  com- 
mitted, but  the  statute  law  says  nothing  about  the  rupture  of  the  hymen  as  a 
necessary  part  of  the  medical  evidence ;  it  requires  from  the  medical  witness 
merely  proof  of  vulvar  penetration — this  may  occur  and  the  hymen  remain 


RAPE  971 

intact.'"*  However,  laws  diflfer,  and  in  any  case  it  would  be  well  to  look  up 
the  wording  and  interpretation  of  the  law  in  the  state  or  country  where  the 
alleged  assault  occurred. 

Infants  and  Children. 

In  the  case  of  infants  and  children  there  are  usually  decided  evidences  of 
injury  about  the  genital  organs.  Of  course,  such  injury  does  not  necessarily 
exist,  but  Avhen  it  does  not  exist  the  proof  of  rape  must  rest  largely  on  evi- 
dence other  than  medical.  xVgain,  where  there  are  evidences  of  injury  about 
the  genitals  in  a  child  alleged  to  have  been  assaulted,  it  does  not  necessarily 
follow  that  the  injuries  are  due  to  rape.  The  abnormal  appearance  may  be 
due  to  some  disease  or  to  some  accidental  injury,  or  to  some  injury  inflicted 
by  a  designing  person  with  the  object  of  deceiving  the  physician.  All  these 
things  must  be  kept  in  mind.  In  this  as  in  other  situations,  the  physician's 
diagnosis  of  the  conditions  present  and  the  interpretation  of  the  meaning  of 
those  conditions  must  be  founded  on  incontrovertible  physical  evidence  that 
will  stand  attack  from  all  sides. 

The  evidences  of  rape  will,  of  course,  vary  much  with  the  time  that  elapses 
after  the  occurrence  before  the  child  is  seen. 

1.  If  the  child  is  seen  within  a  few  hours,  the  following  conditions  may  be 
present : 

a.  More  or  less  abrasion  of  the  vulva  and  vaginal  opening,  with  probably 
some  bleeding  or  clots.  If  penetration  into  the  vagina  has  taken  place,  there 
may  be  extensive  injuries — tearing  of  the  hymen,  perineum,  and  vaginal  walls 
into  the  rectum  or  even  into  the  peritoneal  cavity  (Figs.  236.  237). 

b.  Evidences  of  violence  elsewhere  on  the  body  or  about  the  clothing — 
scratches  or  bruises  on  the  body,  tears  of  clothing,  or  blood  on  same  or  disar- 
rangement of  same.  In  some  cases  the  child  has  been  rendered  insensible  by 
a  blow  on  the  head  or  by  some  drug  administered. 

c.  Presence  of  semen  in  the  vicinity  of  the  genitaL  of  the  child  or  on  the 
clothing.  The  contaminating  material  should  be  submitted  to  microscopic 
examination,  that  the  presence  or  absence  of  spermatozoa  (as  a  positive  evi- 
dence of  semen)  may  be  determined. 

d.  Presence  of  gonorrhoeal  pus  on  the  genitals.  The  presence  of  pus  about 
the  genitals  of  the  child  does  not  necessarily  indicate  rape.  The  pus  may  have 
been  put  there,  with  blood  and  scratches,  for  purposes  of  deception.  If  micro- 
scopic examination  of  the  pus  shows  gonococci,  it  has  come,  directly  or 
indirectly,  from  gonorrhoeal  inflammation  in  a  male  of  female.  Gonorrhoeal 
ophthalmia  is  a  not  infrequent  form  of  gonorrhoeal  inflammation,  and  the  pus 
from  such  a  condition  in  the  mother  or  attendant  may  be  responsible  for  the 
gonorrheal  vulvitis  in  the  child. 

2.  If  the  child  is  seen  after  a  few  days  or  a  week  or  so,  the  following  con- 
ditions may  be  found: 


•  Taylor's  Medical  Jurisprudence:    American  edition  by  Clark  Bell. 


972  MEDICO-LEGAL  POINTS  IN  GYNECOLOGY 

a.  Acute  inflammation,  apparently  due  to  violence.  The  fact  that  inflamma- 
tion is  present  is  established  by  the  presence  of  a  mucopurulent  discharge, 
yellowish  in  color  and  staining  the  linen.  This  may  not  be  present  the  first 
day  or  two,  but  after  that  it  is  ordinarily  present  if  there  has  been  much 
injury  of  the  vulva  or  vagina.  The  inflammation  is  further  indicated  by  the 
redness  of  the  parts,  the  tenderness  and  the  pain  on  urination. 

The  acuteness  or  recent  onset  of  the  inflammation  is  shown  by  the  severity 
of  the  process  compared  with  its  extent,  the  marked  painfulness  of  the  affected 
areas,  the  presence  of  recent  abrasions  and  tears  about  the  hymen  and  vulva, 
and  possibly  swelling  from  edema.  The  parts  may  be  so  painful  that  the  child 
strongly  resists  any  attempt  to  make  an  examination — even  the  separation  of 
the  thighs.  This  is  of  no  diagnostic  significance,  as  children  with  inflammation 
from  other  causes,  or  even  with  no  inflammation,  may  do  the  same.  If  this 
obstacle  to  examination  is  extreme,  it  may  be  necessary  to  anesthetize  the 
child  in  order  to  make  the  examination.  If  extensive  inflammation  is  present, 
there  may  be  fever,  and  in  the  very  extreme  injuries  the  most  serious  acute 
symptoms  may  develop.  Several  deaths  from  this  cause,  with  consequent  con- 
victions for  murder,  have  been  recorded. 

The  fact  that  the  inflammation  was  immediately  preceded  by  violence  or 
mechanical  injury  is  shown  by  the  evidences  of  recent  tears  or  abrasions,  or 
by  ecchymoses  due  to  bruises  from  some  cause,  and  also  by  the  extent  and 
severity  of  the  inflammation  in  such  a  short  time  and  without  other  apparent 
cause.  Gangrene  with  sloughing  of  the  external  genitals  and  vagina  and  adja- 
cent tissues  has  occurred  from  these  causes,  usually  with  fatal  effect,  though 
some  have  recovered  after  considerable  sloughing. 

Care  should  be  taken  to  exclude  similarly  appearing  conditions  due  to  other 
causes.  The  very  severe  inflammation  of  the  genitals  called  "noma"  has 
more  than  once  led  to  a  mistaken  supposition  of  rape.  It  is  seen  principally 
in  debilitated  children  with  severe  acute  diseases,  such  as  scarlet  fever,  diph- 
theria, typhoid  fever,  etc.  Occasionally,  however,  it  occurs  in  apparently 
healthy  children  where  the  genitals  are  neglected  and  dirty,  permitting  some 
severe  infection.  It  may  follow  marked  bruising  or  injuries  of  the  parts  from 
any  cause.  It  may  follow  even  a  comparatively  slight  injury  in  an  otherwise 
healthy  child.  Taylor  relates  a  rapidly  fatal  case  in  a  child  5  years  old  who 
accidentally  fell  on  some  thorns,  from  which  she  sustained  slight  injuries,  fol- 
lowed l)y  a  severe  infection  and  noma  and  death.  The  condition  of  the  parts, 
witli  tlie  evidence  of  mechanical  injury,  were  such  that  it  might  easily  have 
led  to  a  charge  of  rape,  had  the  real  cause  not  been  known. 

b.  Gonorrlioeal  inflammation  in  the  acute  state.  Conorrhoeal  inflammation 
is  likely  to  extend  into  the  uretlira,  tliough  the  vagina  may  escape.  The  diag- 
nosis of  gonorrhoeal  inflammation  is  established  by  finding  gonococci  in  the 
discharge.  The  significance  of  the  presence  of  acute  gonorrhoeal  inflamma- 
tion depends  on  circumstances,  as  already  explained. 

c.  Evidences  of  chancroidal  infection  (page  421). 

d.  There  may  be  present  some  of  the  other  conditions  mentioned  under  the 
earlier  examination. 


RAPE  973 

The  disturbance  of  the  parts  may  be  very  slight,  as  shown  in  cases  where 
other  cireimistanees  proved  the  rape.  For  example,  an  adult  was  convicted 
of  rape  on  an  infant  only  seven  months  old.  According  to  the  medical  evi- 
dence the  vulva  was  somewhat  swollen,  there  was  slight  excoriation  about 
Nthe  lalbia  minora  and  a  small  amount  of  blood.  The  hymen  was  not  lacerated, 
and  there  Avas  no  evidence  of  penetration  past  it.  Seminal  fluid  was  found  on 
the  person  of  the  child. 

The  evidences  of  rape,  when  not  severe,  may  very  quickly  disappear.  Casper 
relates  a  case  of  a  girl  of  8  years  upon  whom  rape  was  committed  by  a  mau 
in  a  drunken  condition.  The  girl  was  examined  the  next  day.  The  labia  were 
then  reddened,  and  there  was  congestion  about  the  vaginal  entrance,  which 
was  very  tender.  Examination  ten  days  later  showed  the  genitals  to  be  in 
their  natural  state,  and  there  was  nothing  at  that  time  to  indicate  that  the 
girl  had  been  subjected  to  violence. 

3.  An  examination  after  some  weeks  or  months  may  show  no  evidence  of 
the  disturbance,  or  may  show  one  or  more  of  the  following  conditions : 

a.  Chronic  muco-purulent  discharge  from  the  vulva  or  vagina.  This  is 
present  in  many  infants  and  young  girls  from  simple  causes,  such  as  want  of 
cleanliness,  scalding  from  frequent  irritating  bowel  movements,  seat  worms, 
irritating  urine,  adherent  prepuce  over  clitoris,  skin  diseases  of  the  vulva, 
pediculi  and  various  other  sources  of  irritation  about  the  genitals. 

b.  Chronic  gonorrhoeal  discharge  from  the  external  genitals  or  vagina. 
The  fact  that  the  discharge  is  gonorriioeal  is  established  by  finding  gonoeocci. 
If  the  beginning  of  this  discharge  can  be  fixed  as  about  the  time  of  the 
alleged  assault,  it  is  strong  corroborative  proof.  Gonorrhoeal  vulvitis  and 
vaginitis  occur,  however,  not  infrequently  from  wholly  different  causes,  as 
previously  stated. 

c.  Evidences  of  syphilis  or  chancroid. 

d.  Laceration  or  destruction  of  hymen.  The  presence  of  the  intact  hymen 
does  not  preclude  rape,  as  previously  explained,  neither  does  the  absence  of 
the  hymen  or  apparent  laceration  of  the  hymen  necessarily  imply  injury  of 
the  membrane  by  rape  or  otherwise,  though  the  condition  of  the  hymen  might 
be  strong  corroborative  proof  in  a  particular  case,  especially  if  it  could  be 
established  by  the  mother  or  the  nurse,  or  a  physician  who  had  made  an 
inspection,  that  there  was,  prior  to  the  time  of  the  alleged  assault,  a  well- 
formed  and  apparently  intact  hymen.  The  hymen  is  very  different  in  shape 
and  appearance  in  different  individuals  (Fig.  209).  Occasionally  it  is  prac- 
tically absent  in  a  child  otherwise  normal. 

e.  Abnormal  size  of  vagina,  as  though  it  had  been  at  one  time  dilated. 
Permanent  marked  dilation  is  not  very  likely  to  follow  a  single  distention 
by  coitus  or  otherwise.  This  condition,  which  is  found  occasionally  in  older 
girls  where  the  question  arises,  is  due  usually  to  repeated  distention  of  the 
vagina,  by  coitus  or  otherwise,  extending  over  a  considerable  period  of  time. 
In  such  cases  the  parts  may  soften  and  relax  to  a  remarkable  extent,  even 
leading  to  the  suspicion  that  child-birth  may  have  taken  place. 


974  MEDICO-LEGAL  POINTS  IN  GYNECOLOGY 

f.  Scars  from  injury  of  the  genitals.  The  genitals  are  exceptionally  well 
protected,  and  are  not  often  injured,  except  by  some  disease  process  or  in 
attempts  at  coitus.  Occasionally  a  child  will  fall  astride  of  some  object  and 
inflict  an  injury.  Again,  injury  may  come  from  attempts  of  the  child  to  intro- 
duce some  foreign  body  into  the  vagina,  though  such  injuries  are  more  likely 
to  be  found  in  girls  somewhat  older.  Scars  about  the  genitals  may,  of  course 
result  from  any  severe  inflammation  or  destructive  process,  and  also  from 
chronic  inflammation  of  milder  grade  when  it  is  accompanied  by  persistent 
scratching,  with  resulting  ulceration. 

Older  Girls  and  Unmarried  Women. 

In  this  class  the  severity  and  certainty  of  the  signs  decrease  and  the  difii- 
culties  of  arriving  at  a  definite  conclusion  increase.  The,  mechanical  injuries 
following  coitus,  or  attempted  coitus,  are  less  marked  and  sooner  disappear, 
and  there  remain  fewer  deviations  from  the  normal.  Again,  in  the  case  of 
older  girls  and  adult  women  the  medical  man  is  likely  to  be  subjected  to 
two  lines  of  questioning — (A)  as  to  whether  or  not  coitus  or  attempted  coitus 
took  place  at  about  the  time  of  the  alleged  assault,  and  (B)  whether  or  not 
coitus  has  ever  taken  place  before,  and,  if  so,  whether  several  times  or  over  a 
considerable  period. 

A.  Evidences  of  Recent  Coitus  or  attempted  coitus.  The  evidences  found 
will,  of  course,  depend  to  a  considerable  extent  on  the  period  of  time  which 
intervenes  between  the  assault  and  the  examination.  If  the  examination  is 
made  within  a  few  hours  after  the  assault,  one  or  more  of  the  conditions  men- 
tioned on  page  971  may  be  found.  The  mechanical  injury  to  the  genitals  is 
likely  to  be  less  because  the  parts  are  larger,  and  the  epidermis  less  delicate 
and  less  easily  abraded.  The  evidence  of  injury  on  other  parts  of  the  body  are 
likely  to  be  more  marked  because  of  the  greater  resistance  which  the  victim  . 
is  able  to  make. 

If  the  examination  is  made  after  a  few  days  or  a  week,  the  additional 
points  mentioned  on  page  972  must  be  investigated.  As  the  local  injuries  are 
less  than  in  younger  females,  they  will  subside  more  quickly. 

If  the  examination  is  made  after  several  weeks  or  months,  the  problem  for 
the  physician  resolves  itself  into  determining  whether  or  not  sexual  inter- 
course Jias  ever  taken  place.  The  determination  of  the  time  when  the  coitus 
took  place  is  ordinarily  impossible  after  several  weeks  have  elapsed.  In  cer- 
tain cases  the  medical  testimony  may  be  strongly  corroborative  of  other  testi- 
mony in  establishing  the  time  of  the  assault,  even  after  several  months.  For 
example,  if  it  should  ]re  establislied  l)y  other  testimony  (a)  that  up  to  the 
time  of  the  assault  tlie  young  woman  was  perfectly  well  and  had  never  had 
coitus,  and  (b)  that  immediately  afterward  she  liad  a  discharge  and  had  been 
sick  more  or  loss  ever  since,  and  (c)  that  there  had  been  no  subsequent 
(;oitus — th(^n  the  finding  of  a  chronic  pyosalpinx  with  chronic  endometi'itis, 
in  an  examirifition  some  months  later,  Avould  be  strong  corroborative  proof 
that  the  infecting  coitus  took  place  about  the  time  of  the  alleged  assault. 


RAPE  975 

Ordinarih',  however,  after  a  few  weeks  all  the  acute  and  sul)acute  evi- 
dences Jiave  subsided,  leaving  only  those  that,  so  far  as  any  distinctive  char- 
acteristics are  concerned,  might  have  been  there  some  months  or  some  years. 
So  the  question  here  is  essentially  whether  or  not  coitus  has  ever  taken  place 
in  the  case  of  the  individual  concerned. 

B.  Evidences  of  Remote  Coitus.  Ordinarily,  it  is  easy  to  tell,  by  a  compara- 
tively superficial  examination,  whether  or  not  a  girl  or  woman  has  probably 
had  coitus.  The  diflfereuces  in  appearance  of  the  external  genitals  and  vagina 
when  coitus  has  taken  place  (especially  if  it  has  taken  place  several  times) 
are  usually  so  marked  that  the  physician  has  little  difficulty  in  distinguish- 
ing them.  This  is  the  general  rule.  There  are,  however,  exceptional  cases 
which  present  many  of  the  ordinary  evidences  of  coitus  when  iu  fact  none 
has  taken  place.  On  the  other  hand,  there  are  persons  who  present  signs 
which  are  considered  almost  pathognomonic  of  virginity  when  in  fact  sexual 
intercourse  has  occurred,  and  not  only  sexual  intercourse,  but  pregnancy  and 
labor  at  full  term.  So,  in  exceptional  cases  it  may  be  very  difficult  to  decide 
certainly  whether  or  not  sexual  intercourse  has  occurred,  and  in  such  a  case 
it  is  particularly  difficult  to  legally  prove  the  same,  for  the  anomalies  must 
then  be  considered. 

The  evidences  of  remote  coitus  or  attempted  coitus  can  be  summed  up  as 
follows : 

1.   Evidences  of  previous  child-birth  at  or  near  term. 

a.  Destruction  of  the  hymen,  leaving  only  irregular  tags  here  and  there 
about  the  vaginal  opening,  with  scar  tissue  between.  This  condition  is  very 
strong  evidence  of  childbirth  at  or  near  term.  It  means  that  there  has  passed 
through  the  vaginal  opening  some  body  large  enough  not  only  to  stretch 
and  lacerate  the  hymen,  but  to  stretch  out  the  vaginal  ring  enormously,  and 
to  so  stretch  and  compress  and  bruise  the  hymen  that  the  subsequent  slough- 
ing and  scar-contraction  has  practically  destroyed  it.  There  is  really  no 
hymen  that  can  be  traced  as  a  circular  ring  of  tissue  with  simply  laceration 
from  intercourse.  The  hymen,  as  such,  is  gone,  and  there  remain  only  irregular 
projecting  particles  of  tissue  (carunculae  myrtiformes)  here  and  there  to 
mark  the  place  where  the  hymen  used  to  be.  Of  course  a  large  tumor — e.  g.,  a 
fibroid — delivered  through  the  vagina  might  do  the  same.  Also,  some  destruc- 
tive inflammatory  process  or  serious  injury  during  childhood  or  later  miglit 
produce  practically  the  same  results,  but  such  conditions  are  rare  and  show 
also  other  evidences.  There  are  cases  of  congenital  deformity  in  wliich  the  hy- 
men may  be  present  simply  as  irregular  tags  of  tissue,  or  it  may,  as  recorded  in 
some  cases,  be  absent  altogether.  In  such  cases  we  would  not  expect  the  scar 
tissue  about  the  vaginal  opening  nor  the  marked  enlargement  of  the  opening. 
So  the  destruction  of  the  hymen  as  described,  when  present,  is  strong  pre- 
sumptive evidence  of  preA'ious  childbirth. 

Suppose  the  hymen  is  not  destroyed — does  that  prove  that  no  cliildl)irt]i  lias 
taken  place?  Not  necessarily.  Occasionally  during  labor  the  liymen  is  sim- 
ply torn  and  then  the  ring  beyond  it  is  stretched  and  torn.    After  labor  the 


976  MEDICO-LEGAL  POINTS  IN  GYNECOLOGY 

portions  may  heal  in  such  a  "way  that  the  hymen  appears  practically  intact. 
Still  rarer  cases  have  been  recorded  in  which  the  hymen  softened  and  dilated 
sufficiently  to  permit  the  child  to  pass  and  then  underwent  involution  to 
about  its  former  size.  Such  a  hymen  is  likely  to  stretch  also  during  coitus 
instead  of  tearing.  The  examination  of  such  a  patient  would  show  an  "intacli 
hymen,"  or,  as  some,  laying  too  much  stress  on  the  condition  of  the  hymen, 
are  wont  to  write,  "virgo  intacta. "  The  absurdity  of  such  a  designation  based 
only  on  the  condition  of  the  hymen  is  well  expressed  by  Taylor  when  he  re- 
marks, ''Such  'virgines  intactae'  have  frequently  required  the  assistance  of 
accoucheurs  and  have  in  due  time  been  delivered  of  children." 

b.  Evidences  of  laceration  or  great  stretching  of  the  perineum,  vagina  and 
pelvic  floor.  These  evidences  are  a  large  vaginal  opening,  close  approach  of 
the  opening  to  the  anus  (partial  destruction  of  perineal  body),  scars  about 
the  opening  or  on  the  perineum,  lax  vaginal  walls  and  lax  pelvic  floor.  These 
have  about  the  same  significance  as  the  destruction  of  the  hymen  above 
mentioned — that  is,  their  presence  is  strong  evidence  of  previous  childbirth 
but  their  absence  is  not  of  much  legal  significance. 

c.  Laceration  of  the  cervix.  The  establishment  of  a  distinct  laceration  of 
the  cervix  is  very  strong  evidence  of  a  previous  parturition  or  operation  involv- 
ing division  of  the  cervical  wall.  There  are  conditions  that  simulate  a  slight 
laceration,  but  a  deep  laceration  Avould  hardly  be  simulated  by  anything  short 
of  some  congenital  deformity,  and  in  such  a  case  there  would  be  likely  to  be 
other  deformities.  Also,  there  would  be  no  scar  tissue,  such  as  is  ordinarily 
found  about  a  laceration  of  the  cervix. 

d.  Evidences  of  previous  lactation.  It  may  be  possible  to  press  some  fluid 
from  the  breasts,  or  the  breasts  may  show  the  enlarged  veins  and  the  white 
striae  (lineae  albicantes)  of  a  previous  distention. 

e.  Evidences  of  a  previous  distention  of  the  abdominal  wall  .  There  may 
be  present  the  striae  (lineae  albicantes)  indicative  of  previous  stretching  of 
the  skin  from  distention  from  pregnancy  or  other  causes.  When  other  causes 
(obesity,  tumor,  ascites)  can  be  eliminated  by  the  history,  such  striae  indi- 
cate previous  pregnancy.  Also,  marked  relaxation  of  the  abdominal  wall  may 
be  due  to  previous  distention  by  pregnancy. 

2.  Evidences  of  previous  abortion.  The  evidences  are  exceedingly  uncer- 
tain in  many  cases  after  a  short  time.  There  may  be  some  slight  lacerations, 
with  resulting  scars,  that  may  be  corroborative  evidence,  especially  partial 
laceration  of  cervix.  Their  presence  may  help  some,  but  their  a])sence  is  of 
no  particular  significance. 

3.  Laceration  of  hymen  and  some  dilatation  and  laxity  of  vaginal  opening 
and  vaginal  canal.  These  are  the  ordinary  evidences  of  coitus  and  are  nearly 
ahvays  present,  especially  if  repeated  coitus  has  taken  place.  Usually  the 
opening  in  a  virgin  hymen  is  so  small  that  the  introduction  of  one  finger  is 
effected  with  some  difficulty  and  causes  pain.  Ordinarily,  after  repeated 
coitus  has  taken  place,  the  vaginal  opening  admits  two  fingers  easily  for 
examination,  and  without  pain,  providing  the  perineal  edge  of  the  opening 
is  carefully  depressed. 


RAPE  977 

In  exceptional  cases  the  hymen  may  remain  intact  after  coitus,  particularly 
in  those  cases  where  the  opening  is  large  and  a  little  stretching  will  accom- 
modate the  male  organ.  Occasionally,  however,  a  hymen  with  a  small  open- 
ing will  remain  intact.  In  such  cases  the  hymen  is  usually  elastic  and  un- 
usually tough,  and  consequently  it  stretches  and  dilates  under  a  force  that 
would  rupture  an  ordinary  hymen.  So  that,  though  it  may  be  said  that  there 
are  many  exceptions  to  the  rule  that  "coitus  ruptures  the  hymen,"  there  are 
\ery  few  cases  in  which  a  hymen  presenting  the  normal  rupture  capacity 
(of  normal  size,  normally  tense  and  having  the  normal  consistency,  elasti- 
city, and  strength)  does  not  rupture  on  first  coitus.  In  doubtful  cases,  then, 
the  physician  should  take  care  to  ascertain  accurately,  not  only  the  presence 
of  the  hymen,  but  also  its  character. 

The  apparent  laceration  of  the  hymen  or  even  the  absence  of  the  hymen, 
while  presumptive  evidence  of  coitus,  is  not  positive  evidence  of  the  same. 
It  may  be  absent  wholly  or  partially  from  congenital  deformity.  It  may  have 
been  destroyed  or  dilated  by  disease  or  injury  in  infancy,  childhood  or  later 
life.  It  may  have  been  lacerated  by  an  operation  or  an  examination.  Its 
apparent  laceration  is,  however,  strong  corroborative  evidence  of  coitus 
when  taken  in  connection  with  the  history  of  the  case,  and  especially  when 
there  is  reliable  testimony  establishing  that  it  was  formerly  intact. 

4.  Evidences  of  a  disease  usually  communicated  in  sexual  intercourse, 
such  as  gonorrhoea,  syphilis,  chancroid,  pediculosis  pubis. 

5.  Evidences  of  uterine  or  tubal  inflammation,  presumably  due  to  infection 
following  labor  or  abortion,  or  coitus. 

Married  Women. 

In  married  women  normal  sexual  intercourse  has,  of  course,  already  taken 
place,  so  that  the  establishment  of  the  fact  of  coitus  is  of  no  help  in  estab- 
lishing rape.  The  medical  evidence,  if  any  is  required,  must  bear  upon  the 
question  of  coitus  by  some  one  other  than  the  patient's  livisband  and  against 
her  resistance. 

The  following  points  should  be  investigated : 

1,  Evidences  of  injury  about  the  genitals,  indicative  of  forced  and  hurried 
coitus.    There  may  be  abrasions,  tears,  bruises  or  bleeding. 

2,  Evidences,  elsewhere  on  the  body  or  clothing,  of  injury  in  resistance. 
There  may  be  bruises  and  scratches,  or  an  excited  or  hysterical  state,  such  as 
might  be  caused  by  a  harrowing  experience.  The  clothing  may  show  tears  or 
blood-stains,  or  contamination  with  dirt  of  the  road  or  disarrangement.  Of 
course  none  of  these  evidences  of  violence  establish  the  crime  of  rape.  They 
only  go  to  show  that  something  was  attempted  that  excited  the  woman's 
resistance.  They  might  have  been  due  to  attempted  robbery  or  to  a  quarrel. 
Again,  they  may  have  been  placed  there  intentionally.  The  woman  may  be 
trying  to  deceive  for  the  purpose  of  extorting  money  or  for  other  reasons. 

3,  Stains  of  spermatic  fluid  may  be  present  on  the  clothing  or  person  of 


978  MEDICO-LEGAL  POINTS  IN  GYNECOLOGY 

■the  -woniau.  If  there  is  any  suspicious  stain,  some  of  the  contaminating  ma- 
terial should  be  submitted  to  microscopic  examination,  that  the  presence  or 
absence  of  spermatoza  may  be  determined.  Any  discharge  in  the  vagina  may 
also  be  examined  microscopically,  but  the  presence  of  spermatoza  in  the 
vaginal  discharge  is  not  of  much  significance  unless  it  can  be  established  that 
no  coitus  with  the  husband  has  taken  place  for  three  or  four  days. 

4.    Disease  ''gonorrhoea,  syphilis,  chancroid')  not  present  in  the  husband. 

The   Question   of   Consent. 

The  question  of  consent  is  often  the  crucial  point  on  the  legal  side  of  these 
cases  of  alleged  rape  in  adult  women,  whether  married  or  unmarried.  This 
question  is,  as  a  rule,  decided  largely  or  wholly  by  testimony  other  than 
medical.  In  some  cases,  however,  the  medical  man  may  be  required  to  give 
testimony  concerning  corroborative  facts.  An  adult  woman  of  ordinary 
health  and  strength  is  supposed  to  make  strong  resistance.  In  such  a  ease, 
if  there  are  no  ob^dous  e^ddences  of  resistance,  the  legal  assumption  is  that 
consent  was  given  and  the  case  is  not  one  of  rape.  It  has  been  claimed  that 
a  scrong  woman  can  make  effective  resistance,  and  therefore  that  an  accusa- 
tion of  rape  by  such  a  woman  is  an  absui^lity.  "Some  medical  jurists  have 
argued  that  a  rape  can  not  be  perpetrated  on  an  adult  woman  of  good  health 
and  vigor,  and  they  have  treated  all  accusations  made  under  these  circum- 
stances as  false."'  This  view  is  too  extreme,  for  there  are  circum.stances  and 
conditions  that  would  make  effective  resistance  impossible  even  by, a  woman 
of  unusual  strength,  as  when  two  or  more  are  combined  in  the  attack  or  when 
the  woman  is  rendered  powerless  by  terror  or  by  exhaustion  from  long  strug- 
gling with  her  assailant.  The  physician  may  be  required  to  state  his  opinion 
regarding  the  possibility  or  probability  that  sexual  intercourse  could  take 
place  A^thout  the  consent  of  the  woman  under  various  circufstances ;  for 
example,  the  following : 

1.  When  a  woman  is  weak  from  age,  sickness  or  other  bodily  infirmity. 
That  coitus  could  be  forced  under  such  circumstances  is  evident. 

2.  "Where  there  is  imbecility  or  other  form  of  mental  irresponsil)ilit3'.  In 
sucli  a  case  consent  in  the  legal  sense  is  impossible. 

3.  "Wlum  the  woman  is  attacked  by  several  persons  or  by  one  person  of 
superior  strength.    Rape  is  unquestionably  possible  under  such  circumstances. 

4.  When  there  is  unconsciousness  or  partial  unconsciousness  from  narcotics 
or  intoxicating  liquors.  Coitusmay  take  place  under  such  circumstances  with- 
out the  consent,  and  in  some  cases  even  witliout  the  knowledge,  of  tlie  woman. 
Many  young  women  are  ruined  in  this  way  in  I  he  "wine-rooms'"  of  our  cities. 
Tliis  fact  is  recognized  in  tlic  law  Avliich  makes  it  a  crime  to  give  a  woman 
intoxicants  with  the  intention  of  stupefying  licr.  so  that  coitr.s  may  take 
place  without  her  consent. 

5.  When  there  is  unconseiousness  or  partial  unconsciousness  from  a  gen- 
eral anesthetic,  such  as  chloroform  or  ether  or  laughing  gas.    The  fact  that 


FOREIGN  BODIES  LEFT  IN  ABDOMEN  979 

rape  may,  and  occasionally  has  l)een,  committed  under  these  circumstances 
is  sometimes  taken  advantage  of  by  designing  persons  to  extort  blackmail 
from  dentists  and  others  who  must,  in  their  work,  anesthetize  or  partially 
anesthetize  patients  without  a  third  party  present. 

Anesthesia  or  partial  anesthesia  of  a  girl  or  woman  without  a  third  party 
present  is  hazardous  for  another  reason.  The  patient,  while  going  under  the 
anesthetic  or  recovering  from  the  same,  may  experience  certain  feelings  or 
hallucinations  that  cause  her  to  really  believe  and  firmly  proclaim  that  sexual 
intercourse  took  place.  Many  such  cases  of  false  accusations,  honestly  made, 
are  on  record.  In  one  instance  "a  young  lady  Avas  accompanied  to  a  dentist 
by  her  affianced  lover,  who  never  left  her  while  the  anesthetic  was  adminis- 
tered and  a  tooth  extracted;  yet  she  could  scarcely  be  convinced  subse- 
quently that  the  dentist  had  not  attempted  to  ravish  her." 

6.  "When  there  is  unconsciousness  or  partial  unconsciousness  from  hypnotic 
sleep.  Convictions  have  occurred  of  undoubted  rape  under  this  condition. 
Also,  false  accusations  may  be  honestly  made  from  sensations  experienced  in 
this  condition.  This  comes  under  partial  or  complete  anesthesia.  Another 
source  of  false  accusations,  honestly  made,  is  mental  aberration  of  various 
kinds — from  well-marked  insanity  to  the  various  functional  nervous  dis- 
turbances. 

7.  When  there  is  unconsciousness  or  partial  unconsciousness  from  fainting, 
syncope,  an  epileptic  seizure,  a  fall  or  a  blow. 

8.  "When  the  woman  is  temporarily  helpless  from  terror  or  from  an  over- 
powering feeling  of  horror  at  her  situation. 

9.  A  woman  may  cease  her  resistance  under  threats  of  death  or  duress. 

FOREIGN  BODIES  LEFT  IN  ABDOMEN. 

This  is  a  subject  the  importance  of  which  is  frequently  not  appreciated  by 
the  physician  until  he  is  involved  in  a  lawsuit  concerning  the  same.  Conse- 
quently, I  think  it  well  to  call  attention  to  the  subject  by  detailing  some 
illustrative  cases,  that  the  danger  may  be  recognized  and  avoided. 

Lawsuit.  Small  Gauze  Strip  Extracted  from  Abdominal  Sinus. — In  a  case  of  retro- 
flexion, Wiggin  did  a  vaginal  fixation  and  also  removed  the  left  ovary.  Suppuration 
followed  presumably  from  the  stump.  Later,  laparotomy  was  performed  for  the 
removal  of  the  ligatures.  This  was  followed  by  an  abscess  in  the  abdominal  wall  and 
a  persistent  sinus.  The  patient  then  went  to  another  institution,  and  later  a  small 
gauze  strip  was  taken  from  the  sinus.     Suit  was  entered  for  $10,000. 

Dr.  Wiggin  contended  that  the  gauze  was  not  the  kind  he  used  in  sponging,  and 
that  the  small  strip  had  probably  been  left  in  the  sinus  while  the  patient  was  being 
dressed  at  the  other  institution.     Verdict  for  the  defendant. 

Lawsuit.  Small  Gauze  Sponge  Removed  by  Secondary  Operation. — The  patient  was 
operated  on  for  appendicitis  by  Gillette.  After  the  abdomen  was  open  it  was  found  that 
the  trouble  was  tubal  pregnancy.  The  appendix  incision  was  closed  and  a  median  incis- 
ion made,  and  through  that  the  operation  was  completed.  About  four  days  after  the 
operation  the  appendix  incision  began  to  discharge  pus.  Gillette  treated  this  sinus 
persistently  under  the  impression  that  it  was  kept  up  by  unabsorbed  kangaroo  tendon, 


980  MEDICO-LEGAL  POINTS  IN  GYNECOLOGY 

which  might  at  any  time  be  wholly  absorbed  and  thus  permit  healing.  After  twelve 
months  of  this  treatment  the  patient  went  to  another  physician,  who,  eighteen  months 
after  the  first  operation,  did  a  secondary  operation  and  found  a  small  gauze  sponge,  after 
which  the  patient  recovered.     Suit  was  entered  for  $5,000. 

In  the  trial  court  the  verdict  was  for  the  defendant  on  the  ground  that  the  cause 
of  action,  if  any  arose,  was  barred  by  the  statute  of  limitation.  The  Circuit  Court  held 
that  the  trial  court  was  in  error  and  reversed  the  decision.  The  Supreme  Court  was 
divided  equally  on  the  subject,  hence  the  decision  of  the  Circuit  Court  was  allowed  to 
stand — verdict  for  the  plaintiff. 

Lawsuit.  Sponge  Left  in  Abdomen. — Baldwin  was  made  defendant  in  a  suit,  and  a 
question  that  assumed  much  importance  in  the  case  was  as  to  whether  the  responsi- 
bility for  the  count  of  the  sponges  lay  with  the  surgeon  or  with  the  nurse. 

The  suit  against  the  surgeon  was  finally  withdrawn,  and  legal  action  was  begun 
against  the  hospital  where  the  operation  occurred. 

Lawsuit.  Sponge  Removed  at  Secondary  Operation. — The  patient  was  operated  on 
for  an  abdominal  tumor  by  Thorne.  Several  months  later  a  secondary  operation  was  per- 
formed by  another  surgeon  and  a  sponge  was  found  in  the  abdominal  cavity.  The 
patient  recovered.  Legal  proceedings  were  begun  against  the  first  operator  (Miss  May 
Thorne)  on  the  ground  that  she  was  guilty  of  negligence  in  not  personally  counting 
the  sponges  used  in  the  course  of  the  operation  before  the  wound  was  closed. 

The  defendant  denied  negligence  and  held  that  the  leaving  of  a  sponge  was  an  acci- 
dent that  could  not  always  be  avoided.  She  further  said  that,  like  a  large  number  of 
other  operating  surgeons,  she  left  the  counting  of  the  sponges  to  a  responsible  nurse — 
considering  that  it  was  the  duty  of  the  surgeon  to  keep  his  or  her  eyes  continually 
upon  the  patient  until  the  wound  had  been  closed. 

The  judge,  in  summing  up  the  case,  said  there  was  no  doubt  that  the  defendant 
was  a  skillful  surgeon,  but  the  question  in  this  case  was  not  as  to  her  skill,  but 
whether  she  had  been  guilty  of  want  of  reasonable  care.  The  points  for  the  jury 
were:  (1)  whether  the  defendant  was  guilty  of  want  of  reasonable  care  in  counting 
or  superintending  the  counting  of  the  sponges;  (2)  whether  the  nurse  was  employed 
by  the  defendant  and  under  her  control  during  the  operation;  (3)  whether  the  nurse 
was  guilty  of  negligence  in  counting  the  sponges;  and  (4)  whether  the  counting  of 
the  sponges  was  a  vital  part  of  the  operation  which  the  defendant  undertook  to  see 
properly  performed. 

After  lengthy  consideration  the  jury  returned  a  verdict  for  the  plaintiff. 

Criminal  Trial.  Sponge  Found  at  Autopsy.  The  patient  was  subjected  to  explora- 
tory laparotomy  by  d'Antona.  A  carcinoma  of  the  liver  was  found,  and  an  unfavorable 
prognosis  given.  The  patient  recovered  from  the  immediate  effects  of  the  operation, 
but  died  after  a  month.  At  the  autopsy  a  gauze  pad,  70  by  40  cm.,  was  found  and 
also  two  liters  of  pus.  The  physicians  who  made  the  post-mortem  examination  gave 
out  a  statement  to  the  effect  that  the  death  was  due  to  the  presence  of  the  sponge 
and  the  peritonitis  and  secondary  pleuritis  resulting  therefrom.  The  public  prosecutor 
then  had  d'Antona  indicted  and  placed  on  trial  for  criminal  negligence. 

The  verdict  was  that  the  patient  would  have  died  from  the  other  causes  present. 
The  prosecutor  then  claimed  that  the  hospital  records  had  been  falsified,  hence  a 
new  trial  was  granted.  In  the  second  trial  ten  experts  were  called  and  they  all 
testified  that  there  was  sufficient  cause  for  death  outside  of  any  influence  which 
the  sponge  within  the  abdomen  might  have  had.  The  trial  was  then  discontinued 
because  of  the  absence  of  prosecuting  evidence. 

This  case  was  reported  by  Prof.  Pio  Foa,  who  stated  that,  if  the  autopsy  had  been 
conducted  by  competent  pathologists,  such  an  erroneous  report  would  not  have  been 
made,  and  the  unfortunate  trials  would  not  have  occurred. 

Lawsuit.  Sponge  Left  in  Abdomen.  The  patient  was  subjected  to  abdominal  section 
by  Schooler.  Later  developments  indicated  that  a  sponge,  sixteen  inches  square, 
had  been  left  in  the  abdomen.     Suit  was  entered  for  $1,500.     Verdict  for  the  plaintiff. 


FOREIGN  BODIES  LEFT  IN   ABDOMEN  9gl 

Lawsuit.  Sponge  Left  in  Abdomen.  The  husband  of  the  plaintiff  was  operated 
on  for  appendicitis  by  Hageboeck.  It  was  charged  that  a  surgeon's  sponge  had  been 
left  in  the  abdomen  and  that  this  caused  an  abscess  which  resulted  in  death.  Suit 
was  entered  for  $50,000. 

In  two  trials  the  jury  disagreed.  It  was  reported  that  in  each  trial  the  jurors  stood 
11  to  1  in  favor  of  the  plaintiff.  The  case  was  to  come  up  for  a  third  trial  the 
latter  part  of  the  year. 

Criminal  Trial.  Forceps  Found  in  Abdominal  Cavity  at  Autopsy.  A  patient  with 
a  large  fibroid  was  operated  on  by  Lassallette.  Death  occurred  a  few  hours  after 
the  operation.     Autopsy  disclosed  a  forceps  in  the  peritoneal  cavity. 

At  the  trial  the  operator  was  condemned  to  two  months  in  prison  for  homicide 
through  negligence.     The  sentence  was  served. 

After  serving  the  sentence,  Lassallette  put  in  a  plea  that  the  patient's  death  had 
not  been  caused  by  the  retention  of  the  instrument,  but  by  nux  vomica.  The  death 
occurred  too  soon  to  have  been  due  to  the  presence  of  the  instrument.  It  was 
proven  that  a  midwife  of  bad  reputation  had  a  bottle  of  nux  vomica  in  her  hand 
at  the  house  on  the  day  of  the  death.  This  was  an  entirely  new  phase.  The  body 
was   exhumed.     Lassallette  was  acquitted. 

Criminal  Trial.  Two  Artery  Forceps  Found  in  Abdomen  at  Secondary  Operation. 
The  patient  was  operated  on  for  ovarian  cyst,  Dec.  22,  1897,  by  Prof.  Kosinski  and  Dr. 
Solman,  in  the  latter's  private  hospital.  After  a  few  days  there  appeared  fever  and 
a  mass,  which  continued.  In  the  meantime  two  artery  forceps  had  been  missed,  and 
it  was  thought  they  might  be  in  the  abdomen.  The  disturbance  persisted,  and  six 
weeks  after  the  operation  the  abdomen  was  reopened  and  the  mass  of  exudate  in- 
vestigated, but  neither  forceps  nor  pus  was  found.  The  patient  was  better  after- 
ward and  went  home,  but  did  not  get  well.  Later  a  hard  mass  developed  near  the 
umbilicus.  Kosinski  still  thought  the  forceps  might  be  in  the  abdomen,  and  insisted 
on  another  operation  and  offered  to  perform  it  gratis.  But  the  sons  would  not  hear 
to  this,  and  the  patient  was  taken  to  several  other  physicians,  one  after  another 
hoping  to  be  cured  without  operation.  Finally,  six  months  after  the  primary  opera- 
tion, the  symptoms  became  acute  and  threatening,  and  the  physician  who  was  called 
in  insisted  that  the  patient  be  taken  to  Kosinski  at  once,  that  he  might  perform  the 
operation,  which  had  then  become  imperative.  This  the  family  refused  to  do  and 
called  in  another  physician,  who  operated.  On  opening  into  the  mass  at  the  pelvic 
brim  he  found  a  cavity  in  which  lay  the  two  artery  forceps.  Both  forceps  had  forced 
an  entrance  into  the  external  iliac  artery.  The  removal  of  the  forceps  was  attended 
with  a  furious  hemorrhage,  from  which  the  patient  died  on  the  table. 

Legal  action  was  entered  against  Kosinski  and  there  was  an  extensive  trial,  with 
an  imposing  array  of  legal  and  medical  talent.  Six  experts  were  appointed  to  testify 
in  the  case — Przewoski  and  Troichij  to  consider  the  pathologico-anatomical  features, 
Krajewski  to  describe  a  modern  laparotomy,  Maksimow  to  criticise  the  operation 
as  performed  in  this  case,  Pawlow  to  consider  the  various  complications  and  mis- 
takes that  may  occur  in  a  laparotomy,  and  Neugebauer  to  supply  the  statistics  which 
might  be  required  in  the  trial.  It  was  for  use  in  this  trial  that  Neugebauer  compiled 
the  list  of  cases  that  he  published  the  following  year  (1900),  which  publication  has 
done  so  much  to  enlighten  the  profession  on  this  subject. 

The  trial  resulted  in  the  acquittal  of  the  accused  as  far  as  causing  the  death  of 
the  patient  was  concerned — it  having  been  shown  that  he  strongly  insisted  on  a  line 
of  treatment  which  would  probably  have  prevented  the  patient's  death  had  the  treat- 
ment not  been  peremptorily  rejected  by  the  family. 

A  curious  clinical  feature  of  this  case  was  that,  during  the  patient's  illness,  a  number 
of  radiographs  of  the  suspicious  area  were  made,  but  not  one  of  them  showed  the 
forceps — the  failure  being  due  doubtless  to  defective  technique. 

Lawsuit.     Artery   Forceps   Extracted    From   a   Sinus.     The  patient  was   subjected   to 


982  MEDICO-LEGAL  POINTS  IN  GYNECOLOGY 

operation  for  a  sarcomatous  growth  in  the  abdominal  v/all  by  Bollinger.  The  patient 
was  three  months  pregnant  at  the  time  of  the  operation.  She  recovered  from  the 
operation  and  was  delivered  at  term  without  any  special  disturbance.  She  became 
pregnant  again.  Her  health  was  excellent  and  she  was  able  to  do  all  her  housework. 
In  the  latter  part  of  the  pregnancy  there  appeared  in  the  operative  scar  a  swelling, 
which  opened  and  discharged  much  offensive  pus.  The  abscess  v/as  still  further 
opened  by  the  family  physician.  Within  a  lew  days  she  was  delivered.  A  few  days 
after  the  delivery  an  artery  forceps  Vv'as  discovered  in  the  abscess  wall.  The  patient 
was  sent  to  the  hospital  and  the  forceps  removed  by  operation.  The  patient  died 
two  days  later. 

The  husband  of  the  patient  demanded  money  of  Bollinger,  which  demand  was 
refused.  He  then  went  to  the  public  prosecutor  and  endeavored  to  have  a  criminal 
prosecution  brought  against  the  surgeon.  The  prosecutor  asked  Bollinger  for  a 
written  statement  of  the  case,  which  was  given.  The  prosecutor  saw  no  evidence  to 
warrant  criminal  proceedings,   and  dropped  the   matter. 

The  husband  then  brought  civil  suit,  and  for  thirteen  months  Bollinger  spent  all 
his  time  defending  himself.  Sensational  reports  appeared  in  the  public  press,  and  it  is 
said  that  the  comic  papers  made  capital  of  it  and  pamphlets  on  the  subject  were 
sold  at  the  cigar  stands.  Though  acquitted,  Bollinger  suffered  irreparable  damage 
from  the  sensational  newspaper  reports  and  the  consequent  notoriety.  He  urges 
strongly  that  some  means  should  be  provided  by  which  reputable  physicians  may 
protect  themselves  from  this   species  of  blackmail   and  newspaper  persecution. 

Criminal  Trial.  Piece  of  an  Instrument  Left  in  Abdomen.  A  Paris  surgeon  lost 
part  of  a  broken  instrument  in  the  abdominal  cavity.  The  patient  died.  The  surgeon 
was  put  on  trial  for  manslaughter  due  to  negligence.     Result  of  trial  not  stated. 

Lawsuit.  Pair  of  Spectacles  Found  in  Abdominsl  Cavity.  The  patient  had  three 
operations — the  first  in  America,  the  second  in  Germany  and  the  third  in  France.  The 
French  surgeon  found  a  pair  of  spectacles  in  the  abdomen.  The  patient  sought  redress 
in  the  courts. 

The  outcome  of  the  trial  is  not  given,  neither  is  it  stated  definitely  who  was  sued. 
Neugebauer,  who  cites  the  case,  blames  the  German  surgeon — noting  that  he  either 
left  the  spectacles  himself  or  missed  finding  them  if  left  by  the  previous  operator. 
Lawsuit  Threatened.  Gauze  Compress  Discharged  Per  Rectum.  The  patient  had 
jected  to  vaginal  section,  for  pelvic  suppuration,  by  :\IacLaren.  It  v.'as  a  very  severe 
case.  There  was  persistent  bleeding  requiring  packing,  and  there  were  two  secondary 
hemorrhages  requiring  repeated  packing.  The  patient  recovered.  Two  months  after- 
ward a  very  offensive  discharge  appeared  and  the  patient  extracted  a  twelve-inch 
strip  of  iodoform  gauze  from  the  vagina. 

Suit  was  threatened  and.  on  the  advice  of  his  attorney,  JMacLaren  paid  the  patient 
a   considerable    sum    to   avoid    further    proceedings. 

Lawsuit  Threatened.  Gauze  Compress  Discharged  Per  Rectum.  The  patient  had 
uterine  fibroids,  which  Borysowicz  removed  by  abdominal  operation.  Three  weeks 
later  a  gauze  compress  was  passed  per  rectum.  Evidently  the  compress  had  'been 
left  in  the  peritoneal  cavity  at  the  time  of  the  operation.  The  patient  recovered  and 
thanked  the  operator  most  gratefully  for  his  services  and  left  him  her  photograph. 
Six  years  later  he  received  a  number  of  letters  from  the  patient's  husband,  threatening 
prosecution  for  malpractice  if  he  did  not  at  once  pay  a  certain  sum.  The  husband 
had  no  doubt  heard  of  a  lawsuit  (Kosinski's?)  then  on  at  Warsaw,  and  thought  it  an 
easy  way  to  obtain   some   money   from   Borysowicz.     Apparently   nothing   came   of   the 

elTort. 

Lawsuit  Threatened.  Forceps  Alleged  to  Have  Been  Passed  Per  Rectum.  .  Tiie 
patient  was  operated  on  for  a  suppurating  ovarian  cyst  by  Tuholske.  It  was  an 
extremely  severe  case,  but  the  patient  recovered  and  regained  her  health  rapidly. 
Twenty  months  later  she  wrote  that  she  had  given  birth  to  a  fine  baby  and  felt  well. 


FOREIGN    BODIES  LEFT   IN    ABDOMEN  983 

Labor  had  been  uncomplicated.  The  account  continues:  "Some  five  or  six  months 
after  that  (more  than  two  years  after  the  operation)  the  husband  called  on  me  and 
stated  that  for  two  or  three  months  his  wife  had  had  some  rectal  trouble,  supposed 
to  be  piles,  and  that  a  week  ago,  under  considerable  suffering,  she  had  passed  a 
forceps  at  stool.  He  brought  it  to  me;  it  was  a  forceps  such  as  is  usually  carried 
as  dressing  forceps  in  a  pocket  case — not  a  hemostat.  I  did  not  claim  ownership. 
At  any  rate,  if  that  forcep  had  been  in  the  pelvis  for  two  and  a  half  years,  during 
pregnancy  and  labor,  without  giving  rise  to  a  symptom  or  modifying  labor,  it  was 
a  remarkable  occurrence.  Three  months  after  this  episode  the  patient  was  reported 
well."  In  a  later  reference  to  the  case,  Tuholske  stated  that  several  demands  were 
made  for  money,  accompanied  by  threats  of  a  suit.  No  attention  was  paid  to  the 
demands  and  finally  they  ceased.  He  expressed  the  opinion  that  it  was  an  attempt 
to  obtain  money  by  blackmail. 

The  Question  of  Deception,  Intentional  or  Otherwise.  The  repeated  occurrence 
of  this  accident  in  the  past  and  the  possibility  of  its  occurrence  at  any  time  gives  an 
opportunity  for  designing  persons  to  obtain  money  under  false  pretenses.  Neuge- 
bauer  calls  attention  to  this  fact,  and  remarks  that,  following  the  newspaper  publicity 
given  the  Kosinski  trial,  a  number  of  damage  suits,  alleging  the  accident,  were  filed, 
and  that  in  most  instances  they  were  cases  of  blackmail  or  extortion. 

A  case  has  been  reported  of  a  patient  who,  following  convalescence  from  an  abdom- 
inal operation,  expelled  pieces  of  gauze  or  thin  cloth  from  the  mouth.  The  patient 
claimed  that  the  expelled  pieces  were  vomited  sponges,  which  had  worked  their  way 
into  the  stomach  from  the  peritoneal  cavity.  Suit  was  threatened.  The  matter  was 
dropped,  however,  when  the  practical  impossi'bility  of  the  occurrence,  as  detailed,  was 
explained  to  the  patient. 

When  discussing  the  subject  of  foreign  bodies  left  in  the  abdominal  cavity,  a 
physician  related  to  me  some  of  the  details  of  a  case  in  which  he  had  been  involved. 
He  performed  an  abdominal  operation,  and,  some  time  following  the  convalescence,  the 
patient  came  to  him  and  exhibited  a  surgical  needle  and  stated  that  the  needle  had 
been  passed  per  rectum.  The  patient's  statement  was  confirmed  b}'  a  physician  who 
claimed  to  have  treated  him  at  the  time  the  needle  was  passed.  Suit  was  threatened. 
On  examination  of  the  needle  the  operator  found  it  was  not  the  kind  he  used  at  the 
operation,  and  he  became  convinced  that  the  alleged  occurrence  was  an  attempt  at 
blackmail. 

The  matter  dragged  along  for  some  time.  The  operator  accumulated  all  the  infor- 
mation he  could  concerning  the  subject  and  concerning  the  parties  involved,  and  finally 
confronted  them  in  such  a  way  that  they  were  forced  to  make  a  written  statement, 
acknowledging  that  the  needle  had  not  been  passed  per  rectum,  as  alleged.  The 
needle  exhibited  had  been  obtained  elsewhere  for  the  purpose  of  threatening  suit 
and  extorting  money. 

Porter  gives  an  account  of  a  peculiar  case  bearing  on  this  subject.  The  operation 
was  for  a  parovarian  cyst  and  hydrosalpinx  and  chronic  appendicitis.  The  con- 
valescence was  normal  and  the  patient  left  the  hospital  twenty-two  days  after  the 
operation,  feeling  well.  Eight  days  later.  Porter  received  a  telephone  message  from 
the  patient's  family  physician,  stating  that  he  had  removed  several  pieces  of  gauze 
from  her  vagina. 

Quoting  from  the  report,  "On  inquiry  from  him  I  learned  that  the  pieces  did  not 
tear  off,  but  came  away,  or  rather  were  removed  with  forceps,  in  the  shape  of  rolls 
about  the  length  and  size  of  a  lead-pencil,  and  after  all  presenting  were  removed 
others  would  present  in  a  few  hours,  requiring  that  he  visit  her  two  or  three  times 
a  day  to  take  them  away.  The  doctor  thought  that  the  pieces  came  from  the  pelvic 
cavity  through  an  openmg  in  the  right  side  of  the  vagina  about  the  size  of  a  lead-pencil. 

"On  the  next  day  but  one  after  learning  of  the  matter.  I  visited  the  patient  at  her 
home  with  her  doctor,  and  found  the  patient  on  a  cot  apparently  suffering  some  pain. 


984  MEDICO-LEGAL  POINTS  IN  GYNECOLOGY 

which  she  said  was  due  to  more  pieces  'coming  down.'  She  did  not  look  sick.  In  reply 
to  my  question  she  said  she  felt  well  until  she  got  a  jolt  on  the  car  on  her  way 
home  and  that  since  then  she  had  been  having  pain,  which  was  worse  at  times, 
and  had  not  been  so  severe  since  the  pieces  began  to  come  away.  The  first  knowledge 
the  doctor  had  of  the  nature  of  the  trouble  came  through  the  patient's  husband,  who 
told  him  that  there  was  a  piece  of  gauze  protruding  from  the  vagina.  I  asked  to  see 
what  had  been  removed  and  was  shown  a  large  number  of  pieces  of  different  texture, 
whereupon  I  remarked  that  the  goods  were  not  such  as  I  had  used  as  sponges,  that 
there  were  more  pieces  than  had  been  used  all  told  in  the  operation,  and  that  conse- 
quently they  had  not  been  left  in  the  woman's  belly  by  me.  It  was  averred  that  they 
could  get  into  her  belly  only  through  the  wound  made  by  me  and  at  the  time  it  was 
made,  because  it  had  been  closed,  healed  by  first  intention,  and  was  still  closed.  The 
patient  facetiously  remarked  that  she  'supposed  she  swallowed  'em.'  'No,'  I.  replied, 
'had  you  swallowed  them  they  would  not  come  out  through  the  vagina.' 

"Dr.  F.  now  asked  the  patient  if  she  thought  more  'pieces  were  down.'  Being 
answered  in  the  affirmative,  he  introduced  a  speculum  and  found  that  she  was  right. 
I  removed  the  speculum,  and,  introducing  my  finger,  came  upon  a  small  wad  of  some- 
thing which,  upon  removal,  proved  to  be  a  piece  of  ordinary  white  muslin  about  three 
inches  wide  by  seven  inches  long,  twisted  into  a  rope  and  doubled  upon  itself  so  as  to 
make  a  small  ball  or  wad.  It  was  perfectly  clean,  and  was  so  saturated  with  what  looked 
and  smelled  like  urine,  that  on  squeezing  between  the  fingers  several  drops  were  squeezed 
out.  I  examined  the  vagina  with  my  finger,  assuring  myself  that  there  were  no  more 
'pieces'  there,  that  there  was  no  hole  leading  into  the  pelvic  cavity  and  that,  in  fact, 
it  was  a  perfectly  healthy  vagina  and  in  nowise  unusual  except  its  cleanliness,  for 
which,  of  course,  the  frequent  wipings  it  received  were  accountable. 

"In  the  presence  of  the  patient,  her  mother-in-law  and  the  doctor  I  said,  pointing  my 
finger  at  the  patient,  'Doctor,  I  don't  know  where  those  rags  came  from,  but  that 
woman  knows  very  well,  and  could  tell  if  she  would.'  The  mother-in-law  objected 
to  my  statement  rather  forcibly,  but  the  patient  said  nothing.  I  then  took  the  doctor 
outside,  told  him  that  the  woman  was  a  malingerer  and  that  we  would  give  her  a 
chance  to  put  some  more  rags  in  for  removal.  We  received  one  more  piece  before 
we  left.  Before  leaving  I  insisted  upon  both  the  doctor  and  myself  making  a  thorough 
inspection  of  the  vagina  with  the  eye  and  the  finger  as  well.  This  was  done,  but  no 
abnormality  was  found.  It  should  be  stated  that  some  of  the  'pieces'  were  tinged  with 
blood,  but  none  of  those  removed  during  my  visit  were  so  tinged." 

Dr.  Porter  exhibited  ten  pieces  of  different  size,  shape  and  texture,  and  continued: 
"Eight  days  after  my  visit,  Dr.  Fisher  reported  'no  more  exhibits.'  So  far  as  I  know, 
no  threat  was  made  of  a  suit  for  damages,  nor  did  the  patient  or  her  mother  seem 
out  of  humor  with  me.  The  husband  was  at  work  and  not  present  during  my  visit, 
although  he  presumably  knew  the  day  before  that  I  was  to  be  there,  as  I  had  sent 
word  that  I  was   coming." 

In  regard  to  the  possible  cause  for  the  deception,  Dr.  Porter  mentioned:  1,  desire 
for  money;  2,  desire  for  sympathy;  .3,  desire  to  avoid  work;  4,  sexual  perversity.  He 
stated  that  during  the  patient's  stay  in  the  hospital  nothing  pointing  to  a  neurotic  con- 
dition was  noted.    Indeed,  she  was  regarded  as  an  unusually  nice  and  agreeable  patient. 

Schaefer  gives  the  details  of  a  case  which  emphasizes  the  fact  that  when  a  piece 
of  gauze  is  found  in. the  abdominal  cavity  it  does  not  necessarily  follow  that  it  was 
left  there  in  a  previous  operation.  The  case  occurred  in  the  practice  of  Pryce  .Jones. 
Jones  was  called  to  see  a  woman  with  an  abdominal  swelling.  This  proved  to  be 
an  abscess,  which  was  opened  and  discharged   a   piece  of  cloth. 

There  had  been  no  previous  operation.  The  woman  was  insane,  and  had  been  in 
the  habit  of  tearing  up  pieces  of  cloth  and  swallowing  them.  The  swallowed  cloth 
had  evidently  caused  ulceration  of  the  stomach  wall,  with  subsequent  perforation  into 
the  peritoneal  cavity. 


OTHER  CONDITIONS  985 

The  noted  intestinal  "hair-balls,"  requiring  operation,  constitute  another  class  of 
foreign  bodies  in  the  abdomen  which  were  not  left  there  by  the  surgeon. 

Again,  the  professional  "knife  swallowers"  and  "glass  eaters"  and  their  amateur 
imitators  must  be  kept  in  mind.  Fortunately  the  menu  of  these  persons  is  limited, 
as  a  rule,  to  household  articles.  However,  some  such  "actor,"  who  has  been  relieved 
of  his  accumulated  load  by  surgical  art,  might,  from  the  intimate  acquaintance, 
acquire  a  taste  for  surgical  forceps  instead  of  the  usual  nails  and  pocket-knives.  In 
that  case  a  condition  might  easily  develop  that  would  make  it  very  uncomfortable  for 
the  previous  operator,  though  wholly  without  fault  on  his  part. 

To  make  absolutely  certain  tliat  no  sponge  or  other  foreign  body  is  left  in 
the  peritoneal  cavity  at  operation  is  a  hard  problem.  The  solution  of  this 
problem  is  considered  on  pages  928-933. 

OTHER  CONDITIONS 

Presenting  Medico-Legal  Points. 

1.  The  various  medico-legal  questions  concerned  with  the  state  of  preg- 
nancy, abortion,  labor  and  the  puerperium  belong  more  strictly  to  obstetrics, 
and  need  not  be  considered  here. 

2.  The  question  of  the  character  of  a  disease  present — particularly  gonor- 
rhoea, syphilis,  or  chancroid — and  the  source  from  which  it  could  have  come, 
and  whether  or  not  it  is  still  transmissible,  are  all  questions  that  may  assume 
medico-legal  importance  under  various  circumstances ;  for  example,  in  suits 
for  divorce,  suits  for  possession  of  children,  suits  for  alimony,  suits  for  dam- 
ages against  individuals  or  corporations,  etc.  Of  injuries,  also,  of  the  genital 
organs  you  may  be  called  to  give  the  nature,  extent,  possible  cause  and  prob- 
able outcome.  All  these  are  simple  clinical  questions,  and  the  information 
regarding  them  may  be  obtained  from  the  clinical  portions  of  this  work. 

3.  Various  questions  in  regard  to  sterility  may  come  up  in  legal  inquiries. 
The  required  information  on  this  subject  is  given  in  Chapter  XIY. 

4.  In  the  case  of  the  death  of  a  woman  or  girl  under  suspicious  circum- 
stances, the  physician  may  be  called  upon  to  make  a  post-mortem  examination 
and  then  to  answer,  as  far  as  possible,  various  questions,  among  which  may 
be  the  following: 

What  pelvic  lesions  were  present? 

What  was  the  probable  cause  of  these  lesions? 

What  was  the  cause  of  death? 

5.  In  coroner's  cases,  and  much  more  so  in  malpractice  suits  (before  or 
after  death),  the  following  questions  may  be  asked  concerning  almost  any 
gynecological  disease : 

What  disease  is  present? 

What  are  the  principal  points  upon  which  your  diagnosis  is  based? 

In  your  opinion  did  the  attending  physician  use  reasonable  care  and 

skill  in  the  diagnosis? 
What  is  the  established  treatment  for  the  disease? 
In  your  opinion  did  the  attending  physician  use  reasonable  care  and 

skill  in  the  treatment? 


986  MEDICO-LEGAL  POINTS  IN  GYNECOLOGY 

6.  In  criminal  eases  and  in  damage  suits  the  physician  testifying  as  an 
expert  may  be  required,  particularly  in  the  cross-examination,  to  explain  in 
detail  various  points  in  the  etiology,  pathology,  symptomatology,  diagnosis, 
treatment  and  prognosis  of  the  affection  under  consideration.  To  answer  such 
questions,  the  physician  must  be  well  grounded  in  all  the  important  facts  and 
theories  of  the  disease,  and  must  be  able  to  give  the  required  explanations  in 
a  few  words  and  in  ordinary  language,  avoiding  the  little-understood  tech- 
nical terms. 

On  important  contested  points  it  is  Avell  to  be  fortified  with  the  names  of 
two  or  three  recognized  authorities  on  that  particular  subject,  with  their 
exact  statements.  This  information  is,  of  course,  held  in  reserve,  to  be  given 
only  if  requested. 


987 


APPP^.NDIX, 


FORMULA. 


The   formulae  may  be  classed  in    two  groups- 
those  for  local  use. 


-those  for    internal  use    and 


FOR  INTERNAL  USE. 

The  various  classes  of  remedies  commonly  used  internally  (by  mouth  or 
hypodermatically)  in  gynecological  cases  are  cathartics,  emmenagogues,  sedatives, 
stimulants,  styptics  and  tonics. 


CATHARTICS. 


Gm. 


^      Sodii  et  Potas.    Tartrat.,  60.  (gij.) 

(Rochelle  Salt) 

Sig.  One  to  three  teaspoonfuls  in  a  glass 
of  water,  each  morning  an  hour  before  breakfast. 

[Used '  especially  in  acute  inflammatory 
conditions  in  the  pelvis.] 

^      Fl.    Ext.    Rhamni  Pursh. 

Aromat.,  60.  (gij.) 

Sig.  Fifteen  to  thirty  drops  each  night  at 
bedtime. 

[Used  as  a  tonic  laxative  in  cases  compli- 
cated by  chronic  constipation.  Increase  the 
daily  dose  to  a  teaspoonful  if  necessary.] 


Gm. 


^ 


Pil.    AJoin.    Belladonna. 

Strychnia,  and  Cascara. 
(P.  D.  &  Co.) 
Sig.     One    pill    each   night,    or  each  night 
an  I  morning  if  necessary. 

[Used  as  a  tonic  laxative  in  chronic  con- 
stipation. Each  pill  contains  aloin  1/5  gr., 
strychnia  1/60  gr.,  extract  of  belladonna  i  gr.. 
and  extract  of  cascara  sagrada  ^  gr.) 

^      Sodii  Phosphat. 

Gran:  Effervesc,  120.  (,3iv.) 

Sig.  Teaspoonful  in  a  glass  of  water,  one  to 
two  hours  after  each  meal. 

[A  mild  laxative,  especially  useful  in  cases 
complicated  by  liver  disease  or  chronic  gastrcK 
duodenitis.  ] 


EMMENAQOQUES. 


^     Manganes.  Dioxid.,  4.  (5i.) 

Div.  Pil.  No.  XXX. 

Sig      One  pill  three  times  daily. 

[May  increase  the  dose  to  two  and  three 
and  even  four  pills,  if  no  disturbance  is 
noticed.] 

^      Apiolini,  6.   (,5iss.) 

Div.  Caps.  No.  xxx. 
Sig.     One  capsule  three  times  daily,    after 
meals. 


^ 


Quin.  Sulphat.                        4.00  (3i 

) 

Ext.  Nucis  Vomic,                0.50  (gr 

viii.) 

Olei  Sabinae,                            1.00  (gr. 

XV.) 

Aloes  Socotrin.,                       030  (gr 

V.) 

Cantharidis.                              1.00  (gr 

XV.) 

Div.  Pil.  No.  xxx. 

Sig.     One  pill  three  times  daily. 

SEDATIVES. 


Dy.smenorrhoea  Mixture. 

Gm. 
Potas.  Bromid.,  5.  (5i.) 

Elixir  of  Guarana  and  Celery,  120.  (,5iv.) 
Sig.     Two  teaspoonfuls  every  4  hours  when 
in  pain. 

Fl.  Ext.  Viburn  Prunifol.,         120.  (.3iv.) 
Sig.     Teaspoonful  every  four  to  six  hours. 


P^ 


^ 


120.  (.5iv.) 


I^       Liquor  Sedans, 
(P.  D.  &  Co.) 

Sig.     Teaspoonful  every  four  to  six  hours. 

[The  Liquor  Sedans  is  more  agreeable  than 
the  plain  viburnum  and  also  more  effective. 
Each  ounce  contains  viburnum  prunifol.  30 
gr.,  hydra.stis  60  gr.,  Jamaica  dogwood  30  gr., 
and  cascara  sagrada,  40  gr.] 


988 


FORMULAE 


Gm. 

or 

c.c. 

^      Sod.  Bromid.,  15.  (5iv.) 

Ess.  Pepsin.,  30.  (5!.) 

Aquae,  q.  s.  ad   60.  (,3ii ) 

Sig.  Teaspoonful  in  sarsaparilla  soda- 
water,  when  sleepless,  and  repeat  after  three 
hours  as  necessary. 

^      Sulphonal.,  4.  (5i.) 

Div.  Chart.  Xo.  i\'. 
Sig.     One  powder  in  a  glass  of  hot  lemonade 
at  10  p.  m.;  when  sleepless. 

Bt-      Phenacetin  ,  2.       (5ss  ) 

Codein.  Phosphat.,  0.18  (gr.  iii.) 

Caffein.  Citrat.,  0.18  (gr.  ui.) 

Div.  Caps.  Xo.  vii. 
Sig.     One  capsule  when  pain  is  severe,  and 
repeat  after  three  hours  as  necessary. 


Gm. 

or 
c.c 

^      Fl.  Ext.  Hyoscyami,  6.   (3iss.) 

Potas.  Citrat.,  10.   (jiiss  ) 

Fl.  Ext.  Zeae,  60.  (gii.) 

Aquae,  q,  s,  ad  120    (oiv.) 

Sig.     Teaspoonful      in     sarsaparilla     soda- 
water,  every  three  to  six  hours  as  ordered. 
[Used  to  relieve  vesical  tenesmus.] 

^      Acid.  Benzoic,  6.  (3iss  ) 

Sodii  Borat.,  8.  (5ii.) 

Aquae,  240.   (gviii.) 

Sig.  Tablespoonful  in  water  three  times 
daily.  In  four  days  reduce  the  dose  to  a 
teaspoonful. 

[Used  when  there  is  a  tendency  to  phos- 
phatic  deposits  from  the  urine,  especially  in 
cases  of  vesico- vaginal  fistvila.] 


STIMULANTS. 


STRTCHXL-i.  ScLPHATE,  1  .30  gT.  hypoder- 
matically  or  by  mouth,  every  four  to  eight 
hours. 

DiGiTAiix,  1/.50  gr.  hypodermatically  or  by 
mouth,  every  two  hours  when  pulse  is  rapid 
and  weak. 

XoRiLiL  Saline  Solution  (8/10%),  given 
intravenously  orsubcutaneously  or  in  the  open 
abdomen  or  per  rectum. 

This  is  useful  in  all  conditions  of  shock. 
It  is  especially  effective  in  shock  due  to  loss  of 
blood  (after  the  bleeding  is  stoppedj. 

If  the  patient  is  nearly  pulseless,  the  empty 
vessels  may  be  at  once  filled  by  intravenous 
injection,  using  a  pint  to  a  pint  and  a  half 
(not  more  at  one  time),  at  a  temperature  of 
100^  F. 

When  the  case  is  not  so  urgent  but  still  a 
quick  effect  is  desired,  the  saline  solution  is 
given  subcutaneously,  one  to  two  pints  under 
the  skin  on  each  side  of  the  chest. 


If  the  abdomen  is  open,  the  peritoneal 
cavity  may  be  filled  with  hot  saline  solution, 
provided  there  is  no  contra-indication  such  as 
a  focus  of  pus  which  might  be  thus  dissem- 
inated. 

For  less  urgent  shock  and  for  stimulating 
kidney  action,  the  warm  saline  solution  is  used 
as  high  enemata,  one  pint  or  more  every  four 
to  twelve  hours. 

In  acute  septic  cases,  continuous  rectal 
absorption  is  secured  by  allowing  the  tepid 
saline  solution  to  flow  into  the  rectum  very 
slowly  —  drop  by  drop,  as  explained  on  p.  697. 

Oxygen  is  a  useful  stimulant  when  respira- 
tion is  shallow  or  when  there  are  lung  compli- 
cations. It  is  administered  by  attaching  a 
tube,  with  a  face-piece  and  water  filter,  to  the 
iron  jar  containing  the  oxygen. 


STYPTICS. 


^      Ergotm.  (Merck),  2.  (jss.) 

Ext.  XucLs  Vomic,  0.36  (gr.  vi.) 

Div.  Caps.  Xo.  xxx. 
Sig.     One  capsule  every  six  hours. 
[Used  in   hemorrhagic  conditions   not  con- 
nected with  pregnancy.] 

^      Ergotin.,  2.       (3ss.) 

Ext.  Xucis  Vomic,  0.36  (gr.  vi.) 

Ext.  Cannab.  Indie, .  0.60  (gr.  x.) 

Div.  Caps.  Xo.  xxx. 
Sig.     One  capsule  every  six  hours. 
[Used  when  tnere  is  associated    pain,  par- 
ticularly of  neuralgic  character.] 

^      Stypticin.,  4.  (5i.) 

Div.  Caps.  Xo.  xxx. 

Sig.     One   cap.sule   every  six  hours,   when 
bleeding  is  present. 

[This    is    an     excellent     anti-hemorrhagic 
remedy,  but   it    is    so    expensive    that   some 


patients  object  to  it.  In  cases  where  it  is 
desired  to  give  a  styptic  for  some  months,  the 
ergotin  capsules  may  be  given  continuously 
and  the  stypticin  capsules  added  during  men- 
struation.] 

^      Ergotin.,  2.  (3ss.) 

Stypticin.,  2.  (3ss.) 

Hydrastinin,  2.  (3ss.) 
Div.  Caps.  Xo.  xxx. 

Sig.     One   capsule  every  six    hours ,  when 
bleeding  is  present. 

^      Fl.  Ext.  Ergot.,  60.  (.51!.) 

Sig.     Half  teaspoonful  every  four  to  twelve 
hours,  when  bleeding  is  present. 

^      Desic.  Thyroid.,  6.  (3iss.) 

Div.  Caps.  Xo.  xxx. 
Sig.     One  capsule  three  times  daily. 


FOIiMLL.B 


989 


(jm. 


^      Calcii  Clilorid.,  20.  (5  v.) 

ElLx.  Sinipl.,  30.  (51.) 

Aquae,  q.  s.  ad    120.  (oi^'O 

Sig.     Teaspoonful  in  water  three  times  iliily. 
[Used  in  hemorrhagic  conditions,  to  increa.sc 
the  coagulability  of  the  blood.] 


Gm. 


^       Adrenalin, 

1-1000  .solution,  1.5.  (.^ss.) 

Sig.     Fifteen   drops   in   water  every  three 
hours  till  bleeding  ceases. 


TONICS. 


^      Tinct.  Ferri  Chlorid.,  30.  (gi.) 

Sig.     Ten    drops   in  a  capsule,  followed  by 
half  a  glass  of  water,  three  times  daily. 

^      Elix.  Iron.,  Quinin., 

and  Strychnin.,  120.  (o^v.) 

Sig.     Teaspoonful  in  half  a  glass  of  water 
tliree  times  daily,  before  meals. 

^       Strychnin.  Nitrat.,  0.06  (gr.  i.) 

Massae  Ferri  Carbonat.,        6.00  (3iss.) 
Quinin.  Sulphat.,  4.00  (3i.) 

Div.  Caps.  No.  xxx. 
Sig.     One   capsule  three   times  daily,  after 
meals. 


^      Liq.  Potas.  Arsenitis,  10.  (Jiiss  ) 

Syr.  Ferri  lodid.,  60.  (.^ii.) 

Sig.     Ten  drops  in  water  three  times  daily 
Increase  to  twenty  drops,  as  directed. 


^      Hydrarg.  Biclilorid., 

Tr.  Ferii  Chlorid., 

Liq.  Acid;  Arseniosi, 

Acid.  Hydrochlor.  dil., 

Syrup.  Sim  pi. , 
Sig      Teaspoonful    in     water    three    times 
daily,  after  meals. 

[This  mixture  is  known  as  the  "  Four 
Chlorides  "  and  is  a  very  effective  tonic  in 
cases   complicated   by   anemia  and  neuroses. 


0.09  (gr.  iss.) 
10.00  (5iiss.) 
10.00  (oiiss.) 
20.00  (5v.) 
120.00  (,5iv.) 


FOR  LOCAL  USE. 

The  various  preparations  used  locally  in  gynecological  cases  are  ointments, 
powders,  solutions,  suppositories  and  tablets. 


OINTMENTS. 


Antiseptic  Ointments. 

Carbolized  Vaseline,  1% 
Carbolized  Zinc  Oxide 

Ointment,  1%. 
Unguentuh  Crede. 

^      Hydrarg.  Bichlorid.,  0.15  (gr.  iiss.) 

Lanolin.,  15.00  (5iv.) 

Ungt.  Aq.  Rosae,  30.00  (,3!.) 

Sig.     Apply  locally,    but  not    to   mucous 
membranes. 

Anti=parasitic  Ointments. 

R       Sulphur.  Precip.,  4.00  (Ji.) 

Vaselini,  30.00  (gi.) 

Olei  Rosae,  q.  s. 

Sig.     Apply  as  directed  twice  daily. 

IvAPOZi's  Petroleum  Salve. 

19^       Petrolati,  25.   (5vi.) 

Olei  Olivae,  10.  (Jiiss.) 

Balsam.  Peru.,  5.  (3i-) 

Sig.     Apply  as  directed  twice  daily. 

Sedative  Ointments. 
(Protective,  Anti-pruritic,  Anesthet^). 

Zinc  Oxide  Ointment. 

Vaseline. 

Ungt.  Aquae  Rosae. 


I^ 


^ 


^ 


R 


^ 


Zinci  Oxidi,  g.  (5ii.) 

Acidi  Carbolici,  1.   (TIXxv.) 

Lanolin.,  30.  (  =  i.) 

Ungt  Aq.  Rosae,  q.  s.  ad  60.  (gii.) 
Sig.     Apply  several  times  daily. 


Zinci  Oxidi, 
Bismuth,  subcarbonat. 
Acidi  Carbolici 
Vaselini, 
Sig.     Apply  as  directed. 


2.   (3ss.) 
2.   (3ss.) 
0.60  (TTLx.) 
30.  (51.) 


Mentholis,  4.  (Ji.) 

Olei  Olivae,  8.  (3ii.) 

Chloroform.,  2.   (3ss.) 

Lanolin  ,  30.   (gi.) 

Sig.     Apply  two  or  three  times  daily. 

Acid.  Salicylici,  1.00(gr.  xv.) 

Creosoti,  1.30  (TTl  xx.) 

Glycerit.  Amyli.,  45.00  (.^iss.) 

Lanolin.,  1.5. 00  (3iv.) 

Sig.     Apply  two  or  three  times  daily. 

Acid.  Carbolici,  1 .00  (ITl.  xv.) 

Hydrarg.  Sulphid.  Rubri.,   0.50  (gr.  ix.) 
Sulphur  Sublimat,  45  00  (^iss.) 

Olei  Bergam.,  1.00  (ITL  xv.) 

Sig.     Apply  as  directed. 


990 


FORMULA 


^ 


Gm. 
or 

C.C. 

Acidi  Carbolici,  0.30  (triv.) 

Bismuth.  Subnitrat.  2.00  (3ss.) 

Ungt.  Hydrarg.  Ammoniat.,  8.00  (5ii) 
Ungt.  Aq.  Rosae,  15.00  (gss  ) 

Sig.     Apply  as  directed. 


^ 


Lassar's  Paste. 

Sulphur.  Sublim., 
Zinci  Oxidi, 
Amyli, 

Acid.  Salicylic  , 
Vaselini, 
Sig.     Apply  as  directed. 


4.00  (5i.) 
4.00  (5i.) 
4.00  (3i.) 
0.60  (gr.  X.) 
30.00  (5i.) 


^       Chloreton., 

Ungt-  Aq.  Rosae, 
Sig.     Apply  as  directed. 

^       Orthoform., 

Ungt.  Aq.  Rosae, 
Sig.     Apply  as  directed. 

^      Cocaine  Hydrochlor., 
Ungt.  Aq.  Rosae, 
Sig.     Apply  as  directed. 


4.00  (5i.) 
30.00  (gi) 


4.00  (5i.) 
30.00  (gi.) 


1.00  (gr.  XV.) 
15.00  (5S3  ) 


^ 


Gm. 


Stimulating  Ointments. 

Ungt.  Picis  Liq.,  4.00  (5i.) 

Zinci  Oxidi,  4.00(51.) 

Ungt   Aq.  Rosae,  8  00  (3ii.) 

Lanolin.,  15.00  (gss.) 

Sig.     Apply  on  strips  of  muslin  as  directed. 


Wilkinson's  Ointment. 


^ 


Sulphur.  Precip., 
Picis  Liquid., 
Saponis  Virid., 
Terrae  Albae, 
Adepis, 
Sig.     Apply  as  directed. 

^       Resorcin., 

Acid.  Salicylic, 
Vaselini  Flav., 
Sig.     Apply  as  directed. 


^       Ungt.  Hydrargyri,  10.00  (5iiss.) 

Ungt.  Belladonnae,  10.00  (Siiss.) 

Ungt.  lodi  Comp.,  .  10.00  (Siiss.) 

Sig.     Apply  under  pressure  bandage. 


10.00  (5iiss.) 
10.00  (5iiss.) 
10.00  (Siiss.) 
6.00  (3iss.) 
15.00  (gi.) 


2.00  (5ss.) 
0.36  (gr  vi.) 
30.00  (gi.) 


POWDERS. 


Antiseptic  and  Drying  Powders. 

PxjLV.    Boric   Acid,    dusted  on   freely 


directed. 

Aristol,  dusted  on  as  directed. 


^ 


w 


"^ 


^ 


Xeroform,, 
Acid.  Boric, 
Sig.     Apply  as  directed. 

Acid.  Tannic, 

Xeroform., 

Acid.  Boric, 
Sig      Apply  as  directed. 
[Astringent  and  antiseptic] 

Zinci  Oxidi, 
Magnes.  Carbonat., 
Salolis, 
Amyli, 
Sig.     Apply  as  directed. 


6.00  (3iss.) 
30.00  (gi.) 

4.00  (3i.) 
6.00  (3iss.) 
30.00  (gi.) 


15.00  (gss.) 
15.00  (gss.) 
15.00  (gss.) 
15.00  (gss.) 


Comp.  Stearat.  of  Zinc 
with  Balsam  Peru.,  30.   (gi.) 

(McK.  &  R.) 
Sig.     Use  as  a  dusting  powder.    • 
[A  pleasant   and    effective    drying    powder 
which  will  turn  water  to  some  extent.] 


^      Acid.  Salicylic,  0.24  (gr.  iv.) 

Acid.  Boric,  30.00  (gi.) 

Iodoform.,  8.00   (3ii.) 

Ess.  Eucalyp.,  q.  s. 

Sig.     Apply  freely  on  the  affected  surface 
several  times  daily. 

[Used  to  check  the  odor  of  sloughing  tissue, 
as  in  malignant  disease.] 


Sedative  Powders. 

^      Anesthesin., 
Acid.  Boric, 
Sig.     Apply  as  directed. 

I^      Chloreton., 
Acid.  Boric, 
Sig.     Apply  as  diiccdv'.. 

^      Orthoform., 
Acid.  Boric, 
Sig.     Apply  as  directed. 

^      Morphia.  Sulphat.,  2.00  (3ss.) 

Cretae  Prep.,  4.00  (3i.) 

Sig.     Apply  twice  daily  as  directed. 


4.00  (5i.) 
30.00  (gi.) 


4.00  (3i.) 
.30.00  (gi.) 


4.00  (3i.) 
30.00  (gi.) 


SOLUTIONS. 


Douche  Solutions. 


^ 


Hydrarg.  P>ichlorid., 
Amnion.  Chlorid., 
Methylene  Blue., 
Aquae,  q-  s.  ad 

Sig.     For  External  Use.     Tablcspoonful  to 
two  quarts  of  hot  water.     Use  as  directed. 


6.00  (3iss.) 
6.00   (3iss.) 
0.001  (gr.  -„\0 
240.00  (gviii.) 


^      Acidi  Carbolici,  120.00  (giv.) 

Glyccrini,  q.  s.  ad   240.00  (gviii.) 

Sig.      For  I'vXternal  ITsc     Tablespoonful  to 
two  quarts  of  hot  water.     Use  as  directed. 


^       Lysol., 

Sig.     For  External  Use. 
two  quarts  of  hot  water. 


240.00  (gviii.) 
Tablcspoonful  to 


FORMUL.E 


991 


I 


Gm. 

or 
c.c. 

^       Potas.  Permanganat. ,  10.00  (oiiss.) 

Aquae,  240.00  (,5viii.) 

Sig.  For  External  Use.  Tablespoonful  to 
two  quarts  of  hot  water. 

^       Pulv.  Aluminum. 

Acetat.,  60.00  (5ii.) 

Sig.  Teaspoonful  of  the  powder  dissolved 
in  two  quarts  of  hot  water.      Use  as  directed. 

^       Formol.,  30.00  (,31.) 

Sig.  Poison.  For  External  Use.  Five 
drops  to  two  quarts  of  hot  water.  Use  as 
directed. 

I^      Zinci  Sulphat.,  1.5.00  (Bss.) 

Alum.,  .   60.00  (5ii.) 

Div.  Chart.  No.  xv. 
Sig.     One  powder  dissolved  in  one  quart  of 
water. 

[A  strong  astringent  douche.] 

^      Acidi  Tanniei,  30.00  (gi.) 

Glycerini,  240.00  (sviii.) 

Sig  For  External  Use.  Tablespoonful  in 
one  quart  of  water. 

[A  strong  astringent  douche.] 

Sedative  Solutions. 

Lead  axd  Opium  Wash. 
^      Liq.  Plumbi  Subacetat.,      30.00  (gi  ) 
Tinct.  Opii.,  60.00  (Sii.) 

Aquae,  q.  s.  ad   240.00  (,3viii  ) 

Sig.  For  External  Use.  Apply  as  a  lotion 
as  directed. 

Alum  and  Lead  Lotion. 
^       Pulv.  Alum.,  2.  r.oss.) 

Sol.  Plumbi  Subacetat.,      2.  (5ss.) 
Aquae,  q.  s.  ad  24U.  (gviii.) 

Sig.  Apply  on  compresses  under  pressure 
bandage. 

Zinci  Sulphat..  0.24  (gr.  iv.) 

Fl.  Ext.  Hydrastis,  .30.00  (gi  ) 

Aquae,  q.  s.  ad  120.00  (,5iv.) 

Sig.     For  External  Use. 

Calamine  Lotion. 

Zinci  Oxidi,  15.00  (gss.) 

Pulv.  Calamin.  Prep.,  6.00  (3iss.) 

Glycerini,  30.00  (51-) 

Liq.  Calcis,  q.  s.  ad  240.00  (.gviii.) 

Sig.     For  External  Use. 


^ 


"^ 


Gm. 
or 
c.c. 

Anesthetic  Solutions. 

Cocaine  Hydhochlorate,  4%  to  20% 
solutions  for  local  application.?,  and  )i%  to  4% 
for  subcutaneous  injection. 

Eucaixe  Hydrochlor.  B.,  same  as  cocaine 
for  subcutaneous  use.  It  is  less  toxic  than 
cocaine,  and,  furthermore,  the  solution  can  be 
sterilized  by  boiling. 

^  Eucain.  Hydrochlor.  B.,  0.10  (gr.  i.ss.) 
Morphia.  Hydrochlor.,  0.02.5  (gr.  .ss.) 
Sodii  Chlorid.,  0.20  (gr.  iii.) 

Aquae  Distil.,  100.00  (giiiss.) 

Sig.     Schleich  Solution,  No.  2. 
[For  producing  local  anesthesia  by  the  in- 
filtration   method.     Sterilize    the  solution   by 
boiling  immediately  before  use.] 


^ 


Miscellaneous  Solutions. 


0.60  (gr.  x.) 
1.30  (gr.  XX.) 
1..30  (lUxx.) 
1.30  (TTL  XX.) 

.30.00  (gi.) 

Apply  as  directed 


Ext.  Cannabis  Indie, 

Acidi  Salicylic, 

Alcohol., 

Ether., 

Collodion.,         q.  s.  ad 
Sig.     For  External  Use. 
twice  daily. 

[For  use  on  dry  warts  (not  the  ordinary 
condylomata)  occurring  about  the  external 
genitals]. 

Ivaiserling  Solution.s. 
The    preservation    of     specimens    by    the 
Kaiserling   method,    so    that    they   retain  the 
natural  colors,  consists  of  the  following  three 
steps. 

Step  1.  Fix  for  one  to  five  days  (according 
to  the  size  of  the  specimen)  in  the  dark,  in  the 
following  solution :  — • 

Potassium  Nitrate,  15.00 

Potassium  Acetate,         30.00 
Formol  (40%  sol.  of 

formaldehyde  gas),  200.00 
Aquae,  1000.00 

Step  2.  Then  place  the  specimen  in  80% 
Alcohol  for  one  to  six  hours  and  then  in  95% 
Alcohol  for  one  or  two  hours.  This  treatment 
with  Alcohol  brings  back  the  original  colors  to 
the  specimen. 

Step  3.  Then  preserve  the  specimen  in  the 
dark,  in  the  following  solution: 

Potassium  Acetate,       200.00  (gviss.) 
Glycerine,  400.00  (.gxiiis-s) 

Aquae,  2000.00  (glxviss) 


(.5ss.) 
(Si-) 

(gviss.) 
(gxxxiiiss.) 


SUPPOSITORIES. 


^ 


Cocain.  Hydrochlor.,  O.lS  (gr.  iii.) 

Olei  Theobrom.,  q.  s. 

Div.  Suppositor.  No.  vi. 

Sig.     For   External  Use.     Use  as  directed. 

[To  be  used  within  the  vagina.] 


Also,  various  manufacturing  firms  put  up 
glycerin-gelatin  suppositories  with  different 
medicines  incorporated,  such  as  protargol, 
hydra.stis,  ichthyol  and  various  combinations- 


TABLETS. 

Different  manufacturing  houses  put  on  the  market  compressed  tablets  for  vagioal  use, 
containing  a  great  variety  of  drugs  and  combinations.  By  looking  over  the  lists  one  can  find 
almost  any  formula  desired. 


INDEX. 

DIAGNOSTIC,   THERAPEUTIC  AND  GENERAL   INDEX. 

Note. — Under  "Examination,  gynecologic"  (page  1004),  the  references  are  arranged  sys- 
tematically as  in  the  text,  instead  of  alphabetically.  Following  this,  under  "Examination" 
(page  1005),  the  references  are  arranged  also  alphabetically. 


Abdomen,  14,  119 
auscultation  of,  29 
contour  of,  14,  120 
discoloration  of,  16,  134 
disinfection  of,  913 
distention  of,  126 
dullness  in,  28,  156 

from  appendiceal  mass,  162 

from  ascites,  157 

from  bladder,  156 

from  kidney  tumor,  167 

from  liver,  156 

from  ovarian  tumor,  163 

from  perirenal  tumor,  169 

from  pregnant  uterus,  156 

from  retroperitoneal  tumor,  165 

from  spleen,  156 

from  tubal  mass,  162 

from  uterine  fibroid,  163 
examination  of,  14,  119 
exploration  of,  675 
foreign  bodies  in,  925,  979 
in  ascites,  126,  156 

in  gynecologic    diagnosis,    119    (see    Diag- 
nosis) 
in  obesity,  25,  27,  121 
in  pregnancy,  129 
in  tumors,  131,  148 
in  tympanites,  126 
inspection  of,  16,  119 
mass  in,  26,  148,  256 

in  right  lower,  149,  269,  270 

in  left  lower,  149,  281 

in  central  lower,  150,  281,  284 

in  right  upper,  152 

in  left  upper,  154 

in  central  upper,  155 
mensuration  of,  30 
movements  of,  134 
palpation  of,  17,  135 
percussion  of,  28,  156 
prominence  of,  17,  120,  160 
regions  of,  20,  135 
right  lower,  21,  138,  149 
shape  of.  15,  120 

in  ascites,  126 
sterilization  of,  913 
tenderness  in,  17,  137 
tension  of,  17,  135 
tumor  of,  132 


Abdominal  adhesions,  731 
antisepsis,  913 

applications,  307    (see  Applications) 
bandage,  952 
diagnosis,  119,  269,  287 
drainage,  716,  923 
dressing,  922 
drainage  cases,  954 
ordinary  cases,  922,  951 
septic  cases,  957 
sterilization,   914 
examination,  14,  119    (see  Examination) 
gynecologic  examination,  14,  119   (see  Ex- 
amination) 
hernia,  124 

hysterectomy,  641,  677 
incision,   919    (see   Incision) 

closure  of,  922 
myomectomy,  641,  657 
operation,  909,  944 
palpation,  15,  137 
section,  909 

after-care  in,  948 
after-treatment  of,  948 

bandage,  952 

bladder,  948 

bowels,  949 

by  days,  948 

constipation,  961 

diet,  949 

dilatation  of  stomach,  961 

drainage,  954 

dressings,  951 

drink,  949 

exercise,  952 

first  day,  948 

fistula,  964 

fourth  day,  950 

Fowler  posture,  722,  959 

hemorrhage,  960 

hernia,  964 

intestinal  obstruction,  962 

intestinal  paralysis,  961 

kidney  insufficiency,  961 

laxatives,  949,  961 

local  suppuration,  962 

nausea,  960 

orders,  948 

pain,  948,  964 

peritonitis,  962 

phlebitis,  963 

993 


994 


INDEX 


Abdominal  section — Cont'd 
after-treatment  of 

position,  948,  957 

pulse,  960 

regular,  948 

restlessness,  948 

second  day,  949 

sedatives,  948 

shock,  959 

sinus,  964 

sitting  up,  952 

stimulants,  959 

strapping,  951 

strychnia,  959 

subsequent  orders,  950 

sutures,  951 

temperature,  962 

third  day,  949 

thirst,  949 

tympany,  961 

uterine  replacement  cases,  959 

visitors,  960 

vomiting,  949,  960 

walking,  952 

wound,  951 
anesthesia  in,  917 
bandage  in,  922 
contraindications  for,  910 
dangers  in,  911 
drainage  in,  954 
dressings  after,  922,  951 
exploratory,  910 
indications  for,  910 
position  of  arms  during,  918 
preparations  for,  911 

assistants,  915 

diet,  913 

disinfection,  913 

dressings,  914 

examination,  912 

face  mask,  915 

general,  912 

gowns,  915 

hand  disinfection,  915 

in  home,  911 

instruments,  914 

kidneys,  912 

laxatives,  913 

nervous  system,  912 

operative  field,  915 

patient,  912 

rubber  gloves,  914 

sleeves,  915 

sponges,  914,  925 

sterilization,  913 

surface  of  abdomen,  913 

sutures,  914 

take  to  hospital,  911 
regular  steps  in,  916 

anesthesia,  917 

closure  of  incision,  922 

dressing,  922 

exploration,  921 
incision,  919 

toilet  of  peritoneum,  921 
rubber  gloves  in,  916 


Abdominal  section — Cont'd 

special  points  in,  923 
drainage,  923 
injuries,  925 
instruments  left,  932 
shock,  924 
sponges  left,  925 
sponges,  929 
supporter,  952 
surface,  sterilization  of,  913 
touch,  17 
wall,  16,  120 

abscess,  121 

fat,  120 

relaxation,  124 

separation  of  recti,  124 

skin,  16 

tumor,  121 
wound,  919 

infection  of,  962 

strapping  of,  952 

suppuration  of,  962 

sutures  in,  922,  952 
Abdomino-rectal  examination,  73 
Abdomino-vaginal  examination,  52 
Abnormal  pregnancy,  242,  251,  254 
Abortion,  179 
criminal,  8,  985 
incomplete,  8 

metrorrhagia  from,  8,  905 
tubal,  769 
Abscess,  705,  729 
appendiceal,  271 

broad  ligament,  257,  259,  712,  737 
ischio-rectal,  257 
of  abdominal    wall,    121     (see    Abdominal 

wall) 
of  Bartholin's  glands,  33,  200,  441 
of  vulvo-vaginal  gland,  33,  200,  441 
ovarian,  277,  699,  730 
pelvic,  257,  705,  725 

acute,  705,  712 

after-treatment,  713 

appendiceal,  138,  271 

bacteria,  698,  745,  751 

broad  ligament,  257,  712 

chronic,  729 

diagnosis,  702,  733 

diffuse,  264,  699,  729 

drainage,  705 

drainage  tubes,  710 

gonococcal.  746 

opening,  708 

ovarian,  699,  730 

prognosis,  712 

streptococcal,  751 

treatment,  705,  743 

tubal,  699,  729 

tubo-ovarian,  699,  730 
pericaecal,  291 
puerperal,  bacteria  in,  751 
stitch-hole,  963 
■suburethral.  211,  438 
tubal,  699,  729 
urethral,  33.  211,  399 
vulvo-vaginal,  33,  200,  441 


INDEX 


995 


Absence  of  hymen,  975 

of  uterus,  854 

of  vagina,  185,  842 
Accessory  Fallopian  tubes,  765 

ovary,  841 
Acid,  oxalic,  916 
Action  of  pessaries,  329 
Acute  dilatation  of  stomach,  961 

endocervicitis,  542 

endometritis,  562 

metritis,  562 

pelvic  inflammation,  698 
cellulitis.  699 
oophoritis,  699 
ovaritis,  699 
peritonitis,  699 
salpingitis,  969 

urethritis,  33,   397 

vaginitis,  386,  413 

vulvitis,  402 
Adenitis,  inguinal,  425 
Adenocarcinoma  of  cervix  uteri,   294,  659 

of  corpus  uteri,  244,  686 
Adenomyoma  of  uterus,   627 
Adherent  labia  minora,  184,  466 

prepuce,   185,   466 

retrodisplacement,   606 
Adhesions,  731 

abdominal,   731 

of  clitoris,  185 

of  external  genitals,  446 

of  Fallopian  tubes,  731 

of  intestines,  731,  736 

of  labia,   185,  446 

of  ovaries,  731 

of  prepuce,  185 

of  uterus,  606 

of  vaginal  walls,   417,  842 

post-operative,  962 

tubercular,    761,    763 
Adhesive  plaster,  951 

vaginitis,  417 
Adjustable  foot-rests,  99 

leg-holders,   99 
Adult,  endometrium  of,  526 
After-care    in    abdominal    section,    948    (see 

Abdominal  section) 
After-treatment,    948 

for  repair  of  cervix,   556 

for  repair  of  pelvic   floor,   493 

in  abdominal  section,  948   (see  Abdominal 
section) 

in  curetment,   582 

in  pelvic  abscess,  713   (see  Abscess) 

in  pelvic  drainage,  722   954 

in  perineorrhaphy,   493 

in  trachelorrhaphy,    556 

in  vaginal  section,  965 
Agents,   antiseptic,   100 
Albicans,  corpus,  803 
Alchohol,   107 
Alexander's  operation,  609 
Amenorrhoea,  851 

causes  of,  852,  857 

classes  of,  851 

diagnosis  of,  851 


Amenorrhoea — Cont'd 

in  the  virgin,  852 

symptoms  of,  851 

treatment  of,  854,  861 
Ampullar  pregnancy,  766 
Amputation  of  Fallopian  tubes,  946 

of  cervix  uteri,   561 

of  corpus  uteri,  947 

partial,  of  cervix  uteri,  557 

supravaginal,   641,    947 
Amyloid  degeneration  of  fibroid,  628 
Anal  fissure,  48 
Anatomy   of   Bartholin's    glands,    35,    379 

of  endometrium,    527 

of  external  genitals,  32,  170,  375 

of  Fallopian  tubes,  609 

of  hymen,  380 

of  ovary,  799 

of  parovarium,  808 

of  pelvic  floor,  467 

of  peritoneum,   535 

of  round  ligament,  535 

of  urethra,  378 

of  uterus,  520 

of  vagina,  381 

of  vulva,  170,  375 

of  vulvo-vaginal  gland,  35,  379 

pelvic,  1,  520,  691 
Anemia,  112 
Anesthesia,  917 

ether  in,  917 

for  diagnosis,  91 

for  examination,  91 

for  operation,  917 

general,  91 

gynecologic  examination  under,    91 

in  abdominal  section,  917   (see  Abdominal 
section) 

local,  73,  322 

paralysis  from,  918 

position  of  arms  in,  918 

preparation  for,  912 

scopolamin  in,  793 
Animal  extracts,  371 
Ani  muscle,  levator,  470 

sphincter,  493 
Anodynes,  73 
Anomalies,  836 

of  bladder,  132,  840 

of  Fallopian  tubes,  765,  841 

of  hymen,  171,  841 

of  ovaries,  841 

of  urethra,  840 

of  uterus,  844 

of  vagina,  186,  842 

of  vulva,  185,  841 
Anus,  49 
Anteflexion,  congenital,  232,  624 

of  cervix,  operation  for,  885 
Anterior  colporrhaphy,  504 

vaginal  section,    942 
Antero-posterior  section  of  pelvis,  1,  3 
Anteversion,  624 
Antisepsis,  abdominal,  913 

in  examinations,  100 

vaginal,  575 


996 


INDEX 


Antiseptic  agents,  100 

preparations  for  examination,  100 
Aphthae  of  vagina,  415 
Apostoli  method,  638 
Appendiceal  abscess,  138 
Appendicitis,  138 
Appendix,  diseases  of,  272 

vermiform,  272 
Applications,   304 

abdominal,   307 

cervical,  321 

cold,  309 

counter-irritant,    310 

dry  heat   308 

for  endometritis,  565,  571 

hot,  307 

intrauterine,  346 

moist  heat,  307 

rectal,  358 

vaginal,  311 

concentrated  solutions,  319 
douches,  311 
powders,  323 
suppositories,  324 
tablets,  324 
tampon-capsules,    327 
tampons.  325 

vulvar,  311.  321 
Apron,  Hottentot,  203 

Arms,  position  of,  during  abdominal  section, 
918    (see  Abdominal  section) 

position  of,  in  anesthesia,  918 
Arrangements,   office,   99 
Artery  forceps.  481 
Ascites,  126,  157 

abdomen  in,  126,  156 

diagnosis  of,  126,  157 
from  fat,   120 
from  tumor,  121 

dullness  in,  157 

percussion  of  abdomen  in,  157 

shape  of  abdomen  in,  126 

signs  of,  157 

wave  in,  25,  27 
Asepsis  in  intrauterine  examination,   100 

in  operations,  913 
abdominal,  913 
vaginal,  944 

in  vaginal  examination,  100 
Aseptic  fever,  962 

technique,  913 
Assault,  indecent,  969 
Assistant  in  office,  99 

in  operations,    915 
Astringents,  321,  371 
Atmocausis  of  Pincus,   353 
Atresia,  congenital,  of  cervix,  255 

congenital,  of  vagina,  185 

of  cerv'ix,  255,  261 

of  hymen,  184,  185 

of  uterus,  255 

of  vagina,  185 

of  vulva,  184 
Atrophic  endometritis,  585 

metritis,  585 
Atrophy  of  uterine  fibroids,  625 


Atrophy — Cont'd 
of  uterus,  589 

Auscultation,  29 
in  pregnancy,  29 
of  abdomen,  29 


B 


Bacillus,  Ducrey,  421 

Backache  in  gynecologic  diagnosis,  302    (see 

Diagnosis) 
Bacteria,  389,  563 

in  cellulitis,  752 

in  endometritis,  562 

in  pelvic    abscess,    698,    745,    751    (see   Ab- 
scess) 

in  peritonitis,  715,  746 

in  puerperal   abscess,   751 

in  pyaemia,  751 

in  pyosalpinx,  746 

in  salpingitis,  746 

in  thrombo-phlebitis,  700 

in  urethritis.  33 

in  uterus,  562 

in  vagina,  384,  413 

in  vaginitis,  413 
Bacteriologic  examination,  35 

for  gonococci,  388 

gynecologic,  34 

securing  discharge  for,  34 
Bag,  hot  water,  308 

ice,  310 
Bags  for  sponges,  929 
Bandage.  581,  924,  951 

abdominal.   924,   951 

in    abdominal    section,    924,    951    (see    Ab- 
dominal section) 

T,   325 
Bartholin's  glands,  35,  379 

abscess  of,  201,  441 

anatomy  of,  35,  379 

examination  of,  35 

palpation  of,  37 
Bathing  in  gynecologic  treatment,   365 
Bed,  examination  in,  106 
Bed-pan,  316 
Bicornuate  uterus,  844 
Bimanual  examination,  52,  238 

gj-necologic,  53 

of  uterus,  53 

palpation,  52,  238 

replacement,  603 
Bivalve  speculum,  78 
Bladder,  anomalies  of,  132,  840 

carcinoma  of.  132 

care  of,  494.  948.  966 

catheterization  of,  966 

diseases  of,  266 

displacements   of.  634 

distended.  130 

percussion  of  abdomen  in,  154 

drainage  of,  519 

exstrophy  of,  132 

injuries  of,  925 

malformation  of,  132 

prolapse  of,  191,  217 


INDEX 


997 


Bladder— Cont'd 

rupture  of,  130 
Bleeding  in  menopause,  851 

senile,  673 
Blood,  112 

examination  of.  111 

retention  of.  185 

supply  of  vulva,  380 

vessels  of  external  genitals,  379,  380 
of  ovary,  539 
of  pelvic  floor,  469 
of  tubes,  693 
of  uterus,  531 
of  vagina,  383 
of  vulva,   381 
Bloody  discharge,  904 

causes  of,  904 

treatment  of,  906 
Body,  Wolffian,  836 
Boiling,  101 

gloves,  104,  914 

instruments,  101,  914 

towels,  914 
Bowels  after  operation.  495 

before  operation,  913 

obstruction  of,   962 

in  pelvic  affections,  743,  913 
Broad  ligament,  138,  535 

abscess,  257,  259,  712,  737 

cyst  of,  260,  832 

haematoma    of,    260 

thrombosis,  700 

tumor  of,  276 

varicose  veins  of,  270 
Brushes,  103 

hand,  103 

in  examination,  103 
Bubo,  422,   425 
Bulbs  of  vestibule,  279 
Buried  sutures,  497,  502 
Byrne's  cauterization  method,  686 


Cachexia,  672 

Caecum,  diseases  of,  273 

Caesarean  section,  659 

Calcareous  degeneration  of  fetus,  283 

Calcification,  628 

Calculi  of  ureters,  259 

of  veins,  797 
Calculus,  ureteral,  259 
Canal  of  cervix,  521 

of  Gartner.  808,  838 

of  Nuck,  452 
Cancer  cases,  classification  of,  659 

curetment  in,  684 

metrorrhagia  from,  667 

of  cervix  uteri,  659 

of  corpus  uteri,  686 

of  ovary,  832 

of  uterus,  245.  294,  659 

of  uterus,  operation  for,  677 

of  uterus,  radical  treatment  for,  673 

x-ray  in,  345,  686 
Capillary  drainage,  954 


Carcinoma,  cervical,  659 
of  bladder,  132 
of  cervix  uteri,  659 
diagnosis,  667 
duration,  666 
etiology,  659 
extension,  663 
hemorrhage,  672 
metastases,  666 
operation,  677 
palliative  treatment,  683 
pathology,  659 
recurrence,  682 
symptoms,  667 
treatment,  673 
varieties,  661 
x-ray  treatment,  686 
of  clitoris,  183 
of  corpus  uteri,  686 
diagnosis,  689 
symptoms,  689 
treatment,  689 
of  endometrium,  686 
of  Fallopian  tube,  796 
of  ovary,  832 
of  rectum,  604 
of  urethra,  434 
of  uterus,   659 
of  vagina,  435 
of  vulva,  183,  434 
of  vulvo-vaginal  gland,  206 
Cards,  history,  12 
Care  of  bladder,  494,  948,  966 

of  pessaries,  336 
Caruncle  of  external  genitals,  440 
urethral,    440 

diagnosis  of,  440 
treatment  of,  441 
Case  record,  11 
Catarrh,  cervical,  544 
Cat-gut  sutures,  481,  490,  555 
Cathartics,  formulae  for,  987 
Catneterization,  966 
Catheters,  sterilization  of,  966 
Cauliflower  excrescence,  297 
Causes  of  amenorrhoea,  852,  857 
of  bloody  discharge,  904 
of  cystocele,  504 
of  dysmenorrhoea,  871,  889 
of  endocervicitis,  543 
of  endometritis,  562,  584 
of  eversion  of  cervical  mucosa,  550 
of  extra-uterine  pregnancy,  764 
of  fibromyoma,  625 
of  gonorrhoea,  384 
of  kraurosis  vulvae,  458 
of  leucorrhoea,  176 
of  menorrhagia,   863 
of  metrorrhagia,  904 
of  papillary  cysts,  818 
of  peritonitis,  715 
of  pruritis  vulvae,   460 
of  retrodisplacement,    597 
of  salpingitis,  698 
of  shock,  924 
of  sterility,  895 


998 


INDEX 


Causes — Cont'd 

of  tubal  pregnancy,  764 

of  vaginitis,  384,   413 

of  vulvitis,  384,  402 
Cauterization,  345,  684 

metliod,  Byrne's,  686 
Cautery,  Paquelin,  345 
Cellulitis,  bacteria  in,  752 

pelvic,  699,  736 

vulvar,  406 
Cervical  applications,  321 

canal,  disinfection  of,  248 

carcinoma,  659 

catarrh,  544 

cyst,  588 

incision,  closure  of,  554 

mucosa,  epithelium  of,  529 
eversion  of,  550 

myoma,  628 

polypi,  562 

hemorrhage  in,  562 

wound,  infection  of,  557 
Cervix  uteri,  adenocarcinoma  of,  659 

amputation  of,  557,  561 

atresia  of,   255,  261 

canal  of,  521 

cancer  of,  659 

carcinoma  of,  659  (see  Carcinoma) 

congenital  atresia  of,  255 

cystic  degeneration  of,  545,  558 

depleting,  344 

dilatation  of,  49,  90,  231,  574 

divulsion   of,   577 

ectropion  of,  234 

elongation  of,  560 

Emmet's  operation  for  lacerated,  551 

epithelioma  of,   294,  661 

erosion  of,  539 

eversion   of,   233,    548 

examination  of,  49,  231 

follicular    degeneration    of,    558 

glands   of,   529 

hypertrophy   of,   560 

in    gynecologic    diagnosis,    231,    291     (see 
Diagnosis) 

infection  of,  542 

injuries  of,  547 

inspection  of,  82,  291 

lacerations  of,  547    (see  Lacerations) 

malformation  of,  255 

malignant   disease    of,    659 

nodule  in,  236 

occlusion  of,  255 

operations,  denudation  in,  554 
for  anteflexion,  885 

technique      of,      551',      557,      561       (see 
Technique) 

partial   amputation  of,  557 

polypi  of,  562 

repair  of,  incision  for,  553    (see  Incision) 
instruments   for,   552 
.   Schroeder's  operation   on,   557 

stenosis  of,  544 

sutures  in,  352,  555 

trachelorrhaphy,  551 

ulcer  of,  541 


Chafing,  410 
Chancre,  249 

soft,  421 
Chancroid,  421 

of  external  genitals,  421 

of  vulva,  181 

phagedenic,  425 
Chancroidal  virus,  421 
Change  of  life,  850 

Chapter  on   gynecologic   diagnosis,   118    (see 
Diagnosis) 

on  gynecologic  examination,  1 
Child-bearing,  7 
Children,  gonorrhoea  in,  401 

leucorrhoea   in,   415 

rape  of,  971 

vaginitis  in,  415 
Chorio-epithelioma,  688 
Chronic  endocervicitis,  544 

endometritis,   567 

gonorrhoea,  398 

metritis,  567 

pelvic  inflammation,  728 
cellulitis,  734 
oophoritis,  738 
ovaritis,   738 
peritonitis,  729 
salpingitis,  729 

urethritis,  399 

vaginitis,  398,  415 

vulvitis,  405 
Cirrhosis  of  ovary,  739 

of  uterus,  589 
Classes  of  amenorrhoea,   851 
Classification  of  cancer  cases,  659 

of  causes  of  displacement,  597 

of  diagnostic  signs,  287 

of  endometritis,  538 

of  examination  methods,  13 

of  fibroid  cases,  627 

of  fibromyoma,  627 

of  fistulae,    506 

of  operations  for  displacement,  609 

of  retrodisplacement  cases,  614 

of  therapeutic  measures,  304 

of  vulvar  diseases,  384 
Cleansing  soap,  103 
Climacteric,  850 
Clitoris.  377 

adhesions  of,  184 

carcinoma  of,  183 

cyst  of,  209 

hypertrophy  of,  204 

malformation  of,  184,  204 
Closure  of  abdominal  incision,  922 

of  cervical  incision,  554 

of  perineal  incision,  490 
Cocaine,  322 
Coccygodynia.  76,  301 
Coccyx,  examination  of,  77 

palpation  of,  77 
Codeine,  494 
Coeliotomy,  909 
Coitus,  difficult,  892 

obstruction  to,  892 

pain  in,  892 


INDEX 


999 


Coitus — Cont'd 

violence  in,  189 
Cold  in  gynecologic  treatment,  309 
Collodion,  100 
Colloid  degeneration,  628 
Colpeurynter,  364 
Colpocele,  189 
Colporrhaphy,  482 

anterior,  504 
Complications,  550 
of  operation,  954 
Compresses,  307,  310 
Conception,  895 
Condylomata,  198,  444 
excision  of,  446 
multiple,  444 
of  external  genitals,  444 
of  vulva,  198,  444 
Confinement,  7 
Congenital  anteflexion,  232 
atresia  of  cervix,  255 
atresia  of  vagina,  185 
malformations,  184,  836 
Congestion  of  pelvis,  864 
of  uterus,  566 
of  vagina,  81 
Conjoined  examination,  52 
Conservative  operation  in  salpingitis,  946 
on  Fallopian  tubes,  946 
surgery,  contraindications  for,  757 
definition  for,  945 
indications  for,  946 
of  Fallopian  tubes,  946 
of  ovaries,  946 
of  uterus,  947 
reasons  for,  946 
Constipation,  961 

Constitutional  treatment,  758,  854 
Constriction,  waist,  366 
Continuous  sutures,  488,  491 
Contour  of  abdomen,  15 
Contraction  of  levator  ani,  42 
Contraindications  for  abdominal  section,  910 
(see  Abdominal  section) 
for  conservative  surgery,  757 
for  curetment,  91 
for  operation,  910 
to  marriage,  385 
Contusion  of  vulva,  457 
Convalescence,  493 
Corona  of  resonance,  157 
Corpus  albicans,  803 
luteum,  803 
luteum,  cyst  of,  811 
uteri,   568 

adenocarcinoma  of,  686 
amputation  of,  947 
cancer  of,  686 

carcinoma  of,    686    (see    Carcinoma) 
infection  of,  562 

in  gynecologic  diagnosis  (see  Diagnosis) 
malignant  disease  of,  686 
Corrections,  dress,  366 
Corset,  366 

Counter-irritation  in  gynecologic  treatment, 
310 


Crab-louse,  412 
Crede's  ointment,  349 
Criminal  abortion,  8,  985 

trials,  985 
Crossen's  gauze-strip  sponges,  929 

puncturing  tenaculum-forceps,    615 

retrodisplacement    operation,    615 
Crown  suture,  489,  491 
Cul-de-sac  of  Douglas,  3,  4 
Cup  and  belt  pessaries,  342 
Curet,  88,  578 

examination  with.  90,  95 

uterine,  88,  572 
Curetment,  95,  571 

after-treatment  in,  582 

contraindications  for,  91 

dangers  of,  91 

diagnostic,  90,  95 

effects  of,  581 

exploratory,  90,  95 

for  endometritis,  571 

in  cancer,  684 

in  doubtful  cases,  96 

in  endometritis,  571 

in  fibromyoma,  639 

in  tuberculosis,  592 

indications  for,  96 

instruments  for,  572 

preparation  for,  571 

steps  in,  572 

technique  of,  572 

therapeutic,  571 
Curettage  (see  Curetment) 
Curetting,    microscopic    examination    of,    96, 

670 
Cylindrical  speculum,  83 
Cyst,  cervical,  588 

dermoid,  821 

follicular,  810 

hydatid,  593 

intraligamentary,  260 

mesenteric,  133 

multilocular  ovarian,  820 

of  broad  ligament,  260,  832 

of  clitoris,  209 

of  corpus  luteum,  811 

of  external  genitals,  446 

of  Morgagni,  809 

of  vulvo-vaginal  gland,  443 

omental,  129 

ovarian,  810 

pancreatic,  133 

papillary,  816 
causes  of,  818 
description  of,  819 
diagnosis  of,  819 
pathology  of,  818 
prognosis  of,  818 
symptoms  of,  821 
treatment  of,  831 

parovarian,  832 

proliferating,  812 

pseudomucinous,  813 

retention,  558 

serous,  of  ovary,  816 

vaginal,  223 


1000 


INDEX 


Cyst—Cont'd 

vulvo-vaginal,  443 
Cystadenoma  of  ovary,  812 
Cystic  degeneration,  545 

of  cervix  nteri,  558 

of  fibroid,  628,  651 
Cystocele,  189,  504 

causes  of,  504 

diagnosis  of,  192,  504 

operation,  technique  of,  505 

pessaries  for,  342 

treatment  of,  504 
Cystoma,  812 

D 

Dam,  rubber,  954 

Dangers  in  abdominal  section,  911   (see  Ab- 
dominal section) 

of  curetment,  91 
Debility,  general",  111 
Decidual  remnants,  97 
Deciduoma  malignum,  688 
Deep  percussion  of  abdomen,  30 
Definition  of  conservative  surgery,  945 

of  menopause,  850 

of  menstruation,  847 

of  metrorrhagia,    867,   904 

of  retrodisplacement,  597 
Degeneration,  calcareous,  of  fetus,  283 

colloid,   628 

cystic,  of  cervix,  545 
of  fibroid,  628,  651 
of  ovary,  810 

fatty,  628 

follicular,  of  cervix,  558 

malignant,  633 

myxomatous,  628 

of  fibroids,  628,  633 
Delayed  menstruation,  9,  851,  857 
Denudation  for  repair  of  cervix,  554 

for  repair  of  pelvic  floor,  484 

in  cervix  operations,  554 

in  fistula,  514 

in  pelvic  floor  operations,  484,  496,  501 
Depleting  cervix,  344 
Dermatitis,  402 
Dermoid  cyst  of  ovary,  821 
Description  of  knee-chest  posture,  367 

of  papillary  cysts,  816 
Detached   sponges,   929 
Development  of  Fallopian  tubes,  836,   840 

of  hymen,  837 

of  ovaries,  840 

of  uterus,  595,  597 

of  vagina,  840 
Diabetes  mellitus.  111 
Diagnosis,  abdominal,   119,  269,  287 

anesthesia  for,  91 

gynecologic,   118 
abdomen  in,  119 
discoloration,  134 
dullness,  156 
mass,  148 
movement,   134 
prominence,  120 


Diagnosis,  abdominal — Cont'd 
abdomen  in 
tenderness,  137 
tension,  135 
backache  in,  302 
cervix  uteri  in,  231,  291 
discharge,    33,    291 
displacement,  51,  231 
distortion,  231 
enlargement,  231 
erosion,  294 

eversion  of  mucosa,  548 
flxation,  237 
hardening,  236 
laceration,  292,  294 
mass  in  canal,  237 
softening,  234 
tenderness,    236 
chapter  on,  118 
corpus  uteri  in,  54,  238 
displacement,   57,   239 
enlargement,  58,  240 
fixation,  59,   256 
hard  nodules,   59,   255 
softening,  59,  255 
tenderness,  59,  256 
methods  of,   118 
pain  in  pelvis  in,  297 
pelvic  mass  in,  256 

mass  low  in  pelvis,  256 

to  right  of  cervix,  firm,   256 
to  right  of  cervix,  fluid,    259 
to  left  of  cervix,  firm,  263 
to  left  of  cervix,  fiuid,    263 
behind  cervix,  firm,  263 
behind  cervix,  fluid,  264 
in  front  of  cervix,  firm,   266 
in  front  of  cervix,  fluid,  266 
filling  pelvis,  firm,   267 
filling  pelvis,  fluid,  268 
mass  high  in  pelvis,  269 
in  right  side,  flrm,  269 
in  right  side,  fiuid,  276 
in  left  side,  firm,  281 
in  left  side,  fluid,  281 
in  center,  firm,  281 
in  center,  fiuid,  284 
table  for,  287 
vaginal,  224 

bleeding  area,  290 
congestion,  289 
mass,  225 
roughening,  224 
tenderness,  224 
ulcer,  290 
vulvar,  224 
discharge.  176 
inflammation,  180 
laceration,  186 
malformation,  184 
swelling,  189 
ulcer,  181 
judgment  in,  117 
leucocytosis  in,  114 
method  of,  118  (see  Diagnosis) 
of  amenorrhoea,  851 


INDEX 


1001 


Diagnosis,  abdominal — Cont'd 

of  ascites,  12()   (see  Ascites) 

of  cystocele.  189 

of  endometritis,   564,   570 

of  extra-uterine   pregnancy,  772 

of  fibromyoma,  634 

of  gonorrhoea,  387 

of  imperforate  hymen,  185,  842 

of  Ivraurosis  vulvae,  181,  458 

of  menopause,   850 

of  menorrhagia,  863 

of  menstruation,  849 

of  metrorrhagia.  867,  904 

of  papillary  cysts,  819 

of  peritonitis,  702 

of  pregnancy,  240 

of  pruritis  vulvae,  460 

of  retrodisplacement,   601 

of  salpingitis.  702.  732 

of  suppuration  of  abdominal  wound,  962 

of  tubal  pregnancy,  772 

of  urethral  caruncle,  210,  440 

of  vaginitis,  387,  413 

of  vulvitis,   ISO,  403 
Diagnostic  curetment,  90,  95 

signs,  classification  of,   287 

table  of  questions,  287 
Diagrams  in  records,  11 
Diet.  950 

Difficult  coitus,  892 
Diffuse  fibromyoma,  628 
Digital  examination,  39,  224 
rectal,  73 
uterine.  96 
vaginal,  39,  224 

palpation.    39,    224 
Dilatation,  39,  224 

acute,  of  stomach,   961 

of  cervix  uteri,  49,  90,  231,  574 

of  vaginal  orifice,  31,  465 
Dilating  forceps,  88,  572 

tents,  90 
Dilators,  uterine,  88,  572 
Diphtheritic  vaginitis,  416 
Diplococcus   of  gonorrhoea,  389 
Directions  for  giving  nutritive  enemata,  725 
Discharge,  32,  176 

bloody,   904 
causes  of.  904 
treatment  of,  906 

from  vulvo-vaginal  gland,  36 

purulent,  32 

securing,  for  bacteriologic  examination,  34 

urethral,  34 
Discoloration  of  abdomen,  134 
Disease,  echinococcus,  of  uterus,  593 
of  pelvis,  798 

gynecologic,  relation  of  insanity  to,  759 

hydatid,  593 

insanity  from,  759 

malignant,  of  uterus,  659 

marriage  as  cause  of,  385 

vesical,  266 
Diseases,  general,  110 

of  appendix,  272 

of  bladder,  266 


Diseases — Cont'd 

of  broad  ligaments,  734,  832 

cysts  of  Kobel's  tubules,  832 

parovarian    cysts,   832 

varicocele,  797 
of  caecum,  273 
of  external  genitals,  170,  384 

abscess  of  vulvo-vaginal  gland,  441 

adhesions,  446 

chancroid,  421 

condylomata,  444 

cyst  of  vulvo-vaginal  gland,  441 

cysts,  446 

eczema,  176,  408 

erysipelas,    405 

follicular  vulvitis,  405 

gangrene,  407 

gonorrhoea,  384 

hematoma,  454 

hernia,  452 

herpes,  411 

hydrocele,  454 

intertrigo,  410 

kraurosis  vulvae,  458 

lacerations,  186 

malformations,  184 

malignant  disease,  434 

pediculosis,  412 

periurethral  abscess,  438 

prolapsus  of  urethral  mucosa,  439 

prurigo,  411 

pruritis  vulvae,  460 

scabies,  413 

stasis  hypertrophy,  448 

syphilis,  427 

tuberculosis,  431 

tumors,  434,  448 

ulcers,  37,  181,  419 

ulcus  rodens  vulvae,  436 

urethral  caruncle.  440 

urethritis,  387,  397,  399 

varicose  veins,  456 

vulvitis,  402 
of  Fallopian  tubes,  698,  729,  762,  765,  796 

catarrhal  salpingitis,  699 

displacements,  699 

neoplasms,  796 

salpingitis,  699,  729 
of  intestines,  281 
of  kidneys,  280 
of  labia,  182,  384 
of  liver,  156 
of  ovaries,  699,  729,  799 

acute  ovaritis,  699 

carcinoma,  832 

chronic  ovaritis.  730 

cystic  tumors,  810 

cysts  of  corpus  luteum,  811 

dermoid  cysts,  821 

fibroma,  831 

follicular  cysts,  810 

glandular  cysts.  813 

hemorrhage,  786 

inflammation,  699,  730 

oophoritis,  699,  738 

ovaritis,  699,  738 


1002 


INDEX 


Diseases — Cont'd 
of  ovaries 

papillary  cysts,  817 

papillomata,  817 

paroophoritic   cysts,   832 

prolapse,  740 

sarcoma,  832 

solid  tumors,  831 
of  peritoneum,  283 
of  spleen,  156 
of  ureters,  259 
of  urethra,  438 

caruncle,  440 

polypi,  440 

prolapse,  439 

.suburethral  abscess,  438 

urethritis,  438 

urethrocele,  439 
of  uterus,  539,  595,  625,  659 

anteflexion,  624 

cancer  of  body,  686 

cancer  of  cervix,  659 

cervical  polypi,  562 

displacements,  595 

endocervicitis,  542 

endometritis,  562 

eversion  of  intracervical  mucosa,  550 

fibromata,  625 

gonorrhoeal  endometritis,  562 

hypertrophy  of  cervix,  560 

inflammation,    542 

infravaginal  hypertrophy   of  cervix,   219 

inversion,  624 

lacerations  of  cervix,  547 

posterior  versions   and   flexions,   597 

prolapse,  619 

sarcoma,  689 

senile   endometritis,   563 

septic  endometritis,  562 

subinvolution,  587 

superinvolution,  589 

supravaginal  hypertrophy  of  cervix,  219 
of  vagina,  384 

acquired  atresia,  842 

acquired  stenosis,  842 

adhesive  vaginitis,  417 

cancer,  435 

cystocele,  504 

cysts,  446 

emphysematous  vaginitis,  417 

fibromata,  448 

gonorrhoeal  vaginitis,   387 

hernia,  452 

prolapse  anterior  wall,  504 

prolapse  posterior  wall,   504 

rectocele,  504 

sarcoma,  436 

senile  vaginitis,  417 

simple  vaginitis,  413 

vaginal  flatus,  477 

vaginitis,  384,  413,  417 
of  vulva,  384 

acne,  405 

adhesions  of  clitoris,   184,    466 

adhesions  of  labia,  184,  466 

anterior  hernia,  452 


Diseases — Cont'd 
of  vulvar*  • 

benign  tumors,  448 

cancer,  434 

chaflng,  410 

chancre,   427 

chancroids,  421 

cysts,  446 

cysts  of  vulvo-vaginal  glands,  443 

diabetic  vulvitis,  408 

diphtheria,  408 

eczema,  408 

edema,  196 

elephantiasis,  196,  448 

erysipelas,   405 

fibroma,  207 

follicular  vulvitis,   180,   405 

gangrene,  407 

gonorrhoeal  vulvitis,  384 

hematoma,    190 

herpes,  411 

hypertrophy  of  clitoris,  204 

inflammation    of    ducts   of  vulvo-vaginal 
glands,  441 

inflammation    of    vulvo-vaginal    glands, 
441 

inguino-labial   hernia,    452 

intertrigo,  410 

kraurosis  vulvae,  458 

lipoma,    448 

myoma,  448 

myxoma,  448 

prurigo,  411 

pruritus  vulvae,  460 

sarcoma,   434 

simple  catarrhal  vulvitis,  402 

syphilides,  430 

thrush,  412 

tumors  of  clitoris,  204,  209 

vaginismus,  892 

varicose  veins,  197,  456 

venereal  ulcers.  419 

verrucae,  444 
urethral,   35 
uterine,  176 
vaginal,  176 
varieties  of,  32,  176 
venereal,  324,  421 
vulvar,   176 
Disinfection,  hand,  916 

methods  of,  916 
in  examination.  100 
of  abdomen,  913 
of  cervical  canal,  248 
of  hands,  100,  916 
of  vagina,  480,  575 
of  vulva,  480 
Disorders    of    menstruation,    851     (see    Men- 
struation) 
Displacement,    classification    of    causes    of, 
597 
of  bladder,  634 
of  Fallopian  tubes,  731,  736 
of  kidneys,  274 
of  ovaries,  736,  740 
of  uterus,  239,  595 


INDEX 


1003 


Displacement — Cont'd 
of  uterus 

anteflexion,  624 
as   a  whole,   595 
classification,  597 
inversion,   624 

normal  position  of  uterus,  596 
of  primary   importance,   597 
of  secondary  importance,  624 
posterior  flexions,  597 
posterior  versions,   597 
prolapse,   616 
supports  of  uterus,  596 
of  vagina,  217 
posterior,  597 
Dissecting  forceps,  481 
Distended  bladder,  130 

percussion  of  abdomen  in,  154,  156 
Distention,  intestinal,  126 

of  abdomen,  126 
Disturbances,  functional,  847 

sexual,  892 
Diverticulum  of  urethra,  213 
Divulsion  of  cervix,  577 
Dorsal  posture,  31 
Double  uterus,  844 

vagina,  185 
Doubtful   cases,   curetment  in,   96 
Douche,  hot  vaginal,  316 
intrauterine,  351 
pitcher,  494,  965 
vaginal,  311 
Douglas,  cul-de-sac  of,  3,  4 
Drainage,  abdominal,  923 
after-treatment  in,  954 
capillary,  954 
dressings  in,  954 
gauze  in,  958 
glass  tube  in,  954 

in  abdominal    section,    954     (see    Abdom- 
inal section) 
in  pelvic  abscess,  710 
in  peritonitis,  721 
of  bladder,   519 
peritoneal,  721 
rubber  tube,  710,  958 
split-tube,  958 
vaginal,  716 
Drains,  rubber,  710,  958 
Dress  corrections,  366 

in  gynecologic  treatment,  366 
Dressings,  abdominal,  922,  951    (see  Abdom- 
inal dressings) 
in  drainage,  954 
vulvar,  580 
Dry  heat  in  gynecologic  treatment,  308 
Ducrey  bacillus,  421 
Duct  of  Gartner,  808,  838 
of  Miiller.  836 
oviducts,  4,  521,  691 
vulvo-vaginal  gland,  35 
Wolffian,  691 
Dudley's    operation   for    dysmenorrhoea,    885 
Dullness     in     abdomen,     28,     156     (see     Ab- 
domen) 
in  ascites,  157 


Duration  of  menopause,  850 
of  menstruation,  849 

Dysmenorrhoea,  857 
causes  of,  871,  889 
Dudley's  operation  for,  885 
in  the  married,  889 
in  the  virgin,  870 
membranous,  870,  873 
treatment  of,  876,  889 
varieties   of,    868,   870 

Dyspareunia,  892 


E 

Echinococcus  disease  of  pelvis,  798 

of  uterus,  593 
Ectopic    gestation,    764     (see    Extra-uterine 

pregnancy) 
Ectropion  of  cervix,  234 
Eczema  of  external  genitals,  176,  408 
Edebohl's  speculum,  572 
Educated  touch,  67 
Effects  of  curetment,  581 
Electricity,  353 

in  fibromyoma,  638 
Electro-cautery,  345 
Elephantiasis  of  labia,  196,  449 

of  vulva,  196 
Elongation  of  cervix  uteri,  560 
Emmenagogues,  formulae  for,  987 
Emmet's  operation  for  lacerated  cervix,  551 

for  lacerated  pelvic  floor,  482 
Emphysematous  vaginitis,  417 
Encysted  fluid,  128 
Endocervicitis,  542,  544 

acute,  542 

chronic,  544 

diagnosis  of,  543 

gonorrhoeal,  543 
Endometritis,  562,  567 

acute,  562 

applications  for,  565,  571 

atrophic,  585 

bacteria  in,  562 

causes  of,  562,  584 

chronic,   567 

classification  of,  538 

curetment  for,  571 

curetment  in,  571 

diagnosis  of,  564,  570 

exfoliative,  873 

fungous,  569 

glandular,  690 

gonorrhoea  of,  562 

hemorrhagic,  569 

hypertrophic,   584 

infected,  562,  567 

interstitial,  568 

pathology  of,  562,  567 

polypoid,  569 

prophylaxis  of,  563 

senile,  563 

septic,  562 

simple,  566,  583 

symptoms  of,  564,  569 

treatment  of,  565,  570 


1004 


INDEX 


Endometritis — Cont'd 
tubercular,  592 
varieties  of,  538 
Endometrium,  anatomy  of,  527 
at  menstruation,  528 
carcinoma  of,  686 
epitlielium  of,  527 
glands  of,  528 
gonorrhoeal,  562 
hyperplasia  of,  583 
inflammation  of,  562    - 
of  adult,  526 
of  infant,  525 
regeneration  of,  581 
senile,  526,  528 
tuberculosis  of,  592 
Endothelioma,  663 
Enemata,  495 
laxative,  961 
nutritive,  725 

directions  for  giving,  725 
indications  for,  725 
materials  for,  725 
post-operative,  725,  961 
pre-operative,  913 
Enlarged    liver,   percussion   of   abdomen   in, 
156 
spleen,  percussion  of  abdomen  in,  156 
uterus,  percussion  of  abdomen  in,  154 
Enterocele,  vulvar,  452 
Enteroclysis,  722 
Epigastric  region,  150,  155 
Epithelioma  of  cervix,  294,  661 
of  vagina,  289,  435 
of  vulva,  183,  205,  434 
Epithelium  of  cervical  mucosa,  529 
of  endometrium,  527 
of  vagina,  383 
of  vulva,  377 
Epoophoron,  808 
Erect  posture,  1,  2 
Ergot  in  fibromyoma,  637 
Erosion,  follicular,   540 
of  cervix  uteri,  539 
papillary,  539 
Erysipelas  of  external  genitals,  405 
Ether  for  examination,  91 

for  operation,  917 
Eversion  of  cervical  mucosa,  233,  548 
causes  of,  548 
diagnosis  of,  548 
treatment  of,  551 
Examination,   gynecologic,   13    (see  note   un- 
der Index) 
abdominal,  14,  119 
anatomy,  16,  18 
auscultation,  30 
inspection,  15 
palpation,  15 
regions,  21,  23 

special  points  of  tenderness,  24,  26 
mass,  27 

fluid  wave,  25,  27 
fat  wave,  27,  28 
percussion,  15 
mensuration,  30 


Examination,  gynecologic — Cont'd 
abdominal 

prominence,  15,  120 
obesity,  120 
mass  in  wall,  121 
ventral  hernia,  124 
relaxation  of  wall,  124 
separation  of  recti,  124 
tympanites,  126 
fecal  impaction,  126 
ascites,  126 
encysted  fluid,  128 
pregnant  uterus,  129 
distended  bladder,  129 
pelvic  tumor,  131 
abdominal  tumor,  132 

movement  of  wall,  184 

discoloration  of  wall,  15,  134 

tension  of  abdomen,  15,  135 

tenderness,  15,  137 

in  right  lower  abdomen,  138 
in  left  lower  abdomen,  140 
in  central  lower  abdomen,  140 
in  lumbar  region,  142 
in  right  upper  abdomen,  143 
in  left  upper  abdomen,  144 
in  central  upper  abdomen,  146 
in  umbilical  region,  1-47 
diffuse,  147 

mass  felt,  22,  148 

in  right  lower  abdomen,  149 
in  left  lower  abdomen,  149 
in  central  lower  abdomen,  150 
in  right  upper  abdomen,  152 
in  left  upper  abdomen,  154 
in  central  upper  abdomen,  155 

dullness,  28,  156 
from  liver,  156 
from  spleen,  156 
from  pregnant  uterus,  154 
from  distended  bladder,  154 
from  ascites,  157 
from  encysted  fluid,  162 
from  pelvic  tumor,  163 
from  abdominal  tumor,  165 
from  kidney  tumor,  165 
from  perirenal  lipoma,  169 
of  external  genitals,  31,  170 

anatomy,  32,  170 

discharge,  32,  176 

inflammation,  37,  180 

ulcer,  37,  181 

swelling,  38.  189 

new  growth,  38,  205 

malformation,  184 

hymen,  38 

perineum,  39 

laceration.  39,  186 
vaginal    (digital),  39,  224 

method,  39 

vaginal  walls,  42,  225 

base  of  bladder,  43 

urethra,  44 

vulvo-vaginal  glands,  44,  202 

pelvic  floor,  44,  186,  189 

rectum,  48 


INDEX 


1005 


Examination,  gynecologic — Cont'd 
vaginal 

cervix  uteri,  49,  231,  237 
pericervical  tissues,  52 
vagino-abdominal    (bimanual),  52,  239 
uterus,  53,  238 

position,  53,  239 

size,  56,  240,  244 

shape,  56 

consistency,  56,  255 

tenderness.  56,  256 

mobility,  56,  256 

attachments,  57,  256 

displacement,  239 

enlargement,  240,  244 

softening,  255 

hard  nodules,  255 
lateral  regions,  58 

tube,   60 

ovary,  60 

ureter,  65 
mass  or  induration,  256 

in  right  lower,  firm,  256 

in  right  lower,  fluid,  259 

in  left  lower,  263 

behind,  firm,  263 

behind,  fluid,  264 

in  front  lower,  firm,  266 

in  front  lower,  fluid,  266 

filling  lower  pelvis,  firm,  267 

filling  lower  pelvis,  fiuid,  268 

in  right  side,  high,  firm,   269 

in  right  side,  high,  fluid,   276 

in  left  side,  high,   281 

in  median,  high,  firm,  281 

in  median,  high,  fluid,  284 

table  of  diagnostic  points,  287 
educated  touch,  67 
train  one  hand,  69 
use  two  fingers,  70 
deep  examination,  70 
drawing  down  uterus,  70 
position  of  examiner,  71 
varying  conditions,  71 
intestines  in  way,  72 
diminish  tenderness,  73 
recto-abdominal  palpation  in,  73 
disadvantage,  73 
when  useful,  74 
of  virgin,  74 

recto-vagino-abdominal,  75 
palpation  of  coccyx  in,  77 
instrumental,  77 
by  speculum,  77 

instruments,  77 

steps,  80 

Information  to  obtain,  81 

difficulties,  82 

cylindrical  speculum,  83 

Sims'  speculum,  83 
by  excision  of  tissue,  86 
by  sounding  uterus,  87 

steps,  87 

indications,  88 

contraindications,  89 

information  to  obtain,  88 


Examination,  gynecologic — Cont'd 
instrumental 

by  curetting,  90 

of  vaginal  walls,  289 
congestion,  289 
bleeding,  290 
ulcer,  290 

of  cervix,  291 
normal,  291 
discharge,  291 
lacerated,  294 
eroded,  294 

malignant  disease,  294 
under  anesthesia,  91 

preparations,  91 

vagino-abdominal  palpation,  91 

recto-abdominal   palpation,   92 

recto-vagino-abdominal  palpation,  94 

recto-vesical  palpation,  92 

curetment,  95 

collecting  curettings,  96 

exploration    of    interior   of   uterus   with 
finger,  96 

excision  of  tissue,  97 
preparations  for,  98 

office  arrangements,   99 

directions  to  patient,  99 

antiseptic  preparations,  100 

soap,   103 

brushes,  103 

lubricant,  104: 

rubber  gloves,   104 

specimens,  107 
non-gynecologic  examination  methods,  110 

urine.  111 

blood.  111 

sputum,  115 

nervous  system,  116 
Examination,    abdominal,    14,   119,   287    (see 
note  under  Index) 
abdomino-rectal,  73 
abdomino-vaginal,  52 
anesthesia  for,  91 
antisepsis  in,  100 
antiseptic  preparations  for,  100 
bacteriologic,  35 

for  gonococci,  388 

securing  discharge  for,  33 
bimanual,  52.  238 

of  uterus,  53 
brush  in,  103 
by  lamp,  82 
chapter  on,  1 
conjoined,  52 
digital,  of  vagina,  39 
disinfection  in,  100 
ether  for,  91 
gloves  in,  40 

gynecologic,  13    (see  note  under  Index) 
history  in,  1 
■    in  bed,  106 

in  standing  posture,  50 
instrumental,  77 

by  curet,  90,  95 

by  excision,  86,  97 

by  Sims'  speculum,  84 


1006 


INDEX 


Examination — Cont'd 
instrumental 
by  sound,  87 
by  speculum,  77 
intrauterine,  asepsis  in,  101 
judgment  in,  13 
knee-cbest  posture  in,  72 
left  band  in,  69 
metbods  of,  13 
metbods,  classification  of,   13 

non-gynecologic,  110 
microscopic,  of  curetting,  96,  670 
of  excised  tissue,  97,  670 
of  pus,  35,  388 
of  abdomen,  1-4,  119 
of  Bartbolin's  glands,  35 
of  blood,  111 
of  cervix  uteri,  49,  231 
of  coccyx,  77 

of  external  genitals,  31,  70,  171 
of  Fallopian  tubes,  60 
of  kidney,  274 
of  nervous  system,  116 
of  ovary,  60 
of  pelvic  floor,  44 
of  rectum,  48 
of  sputum,  115 
of  ureter,   68 
of  uretbra,  44 
of  urine.  111 
of  uterus,  53 
of  vagina,  39,  79 
of  virgin,  74 
of  vulva,  31 

of  vulvo-vaginal  glands,  44 
office   arrangements  for,  99 
order  of,  13 
pelvic,  52,  91 
physical,  13 
preparations  for,  98 
record  of,  11 
rectal,  48,  73 
recto-abdominal,  73 
recto-vagino-abdominal,  75 
rubber  gloves  in,  104 
soap  in,  103 
specimens  from,  107 
two  fingers  in,  70 
tympanites  in,  126 
under  anestbesia,   91 

curetment,  95 

digital  of  uterine  cavity,  96 

excision  of  tissue.  97 

recto-abdominal,    92 

recto-vagino-abdominal,  94 

recto-vesical,  95 

vagino-abdominal,  91 
uterine  digital,  96 
vaginal,  39,  224 

asepsis  in,  100 
vagino-abdominal,  52 

Fallopian  tubes,  60 

general  observations,  66 

lateral  regions,   58 

other  regions,  63 

ovaries,  66 


Examination — Cont'd 

vagino-abdominal 
uterus,  53 

wben  required,  13 
Examining  fingers,  40 

band,  40 

table,  98 
Excised  tissue,  microscopic  examination  of, 

97,  670 
Excision,  examination  by,  86 

of  condylomata,   446 

of  vulva,   451 

technique  of,  451 

of  warts,  445 
Excrescence,    cauliflower,    297 
Exercise,  369 

Exfoliative  endometritis,  873 
Explanation,    judgment   in,    to    patients,   758 
Exploration,   intrauterine,   96 

of  abdomen,  96 
Exploratory     abdominal     section,     675,     944 
(see  Abdominal  section) 

curetment,  90,  95 

vaginal  section.  944 
Exstrophy  of  bladder,  132 
External  genitals,  375 

adhesions  of,  446 

anatomy  of,  32,   170,  375 

blood  vessels  of,  379,  380 

caruncle  of,  440 

chancroid  of,  421 

condylomata  of,   444 

cysts  of,  446 

diseases  of,  384    (see  Diseases) 

eczema  of,  176,  408 

erysipelas  of,  405 

examination  of,  31,  170,  171 

gonorrhoea  of,  384 

hematoma  of,  454 

hernia  of,  452 

herpes  of,  411 

hydrocele  of.  454 

hyperesthesia  of.  464 

inliammation  of,  36,  180 

injuries  of,  457 

inspection  of,  31,  170 

intertrigo   of,   410 

lacerations  of,   184 

malformations  of,  184 

malignant  disease  of,  434 

pediculosis  of,  412 

periurethral  abscess  of,  438 

swelling  of,  38,  189 

syphilis   of,   427 

tumors  of.   434.  448 

ulcers  of,  37.  181,  419 

ulcus  rodens  of,  436 

urethritis  of.  387.  397.  399 

varicose  veins  of,  456 
Extirpation  of  vulva,  451 
Extracts,  animal,  371 

of  ovary,  807 
Extra-uterine  fetus,  283 

gestation,  764 

pregnancy,  causes  of,  764 
ampullar,  766 


INDEX 


1007 


Extra-uterine  pregnancy — Cont'd 

diagnosis  of,  772 

hemorrhage  in,  766 

interstitial,  251 

pain  in,  773 

treatment  of,  790 

shoclv  from,  776 

symptoms  of,  772 

signs  of,  778 
Exudates,  257 
pelvic,    699,   729 

F 

Face  mask  for  operator,  915 
Fallopian  tubes,   691 

accessory,  765 

adhesions  of,  731,  736 

amputation  of,   946 

anatomy  of,  691 

anomalies  of,  765,  840 

carcinoma  of,   796 

conservative  operations  on,  946 

conservative  surgery  of,  945 

development  of,   837 

diseases  of,  698,  729,  762,  765,  796  (see  Dis- 
eases) 

displacement  of,  731,   736 

examination  of,  60 

gonorrhoea  of,  681 

hemorrhage  from,  786,  793 

infection  of,   699 

inflammation  of,   699 

malformation   of,   840 

malignant  disease  of,   796 

neoplasms   of,    796 

occlusion  of,  699,  729 

palpation  of,   61 

papilloma  of,  796 

resection  of,  946 

rudimentary,  765 

rupture  of,  766 

tuberculosis  of,   762 

tumors  of,  796 
Fat  in  abdominal  wall,  120   (see  Abdominal 

wall) 
Fatty  degeneration,   628 
Fecal  fistula,  506 
Female  form,  2 
Fermentation  fever,  962 
Fetal  heart  sounds,  29 

membranes,  96 

movements,  27 

uterus,  522 
Fetus,  calcareous  degeneration  of,  283 

extra-uterine,  283 
Fever,  112 

aseptic,  962 

fermentation,  962 

in  leucocytosis,  113 
Fibroid,  amyloid  degeneration  of,  628 
cases,  classification  of,  627 
questions  for,  636 

cystic  degeneration  of,  628,  651 
degeneration  of,  628 

hemorrhage  in,  631 


Fibroid — Cont'd 

interstitial,  626 

intrallgamentary,   627 

metrorrhagia  from,  631 

of  round  ligament,  448 

of  uterus,  radical  treatment  for,  641 

pediculated,  626 

submucous,  627 

subperitoneal,  625 

tumor,    infection    of,    629 

uterine,  atrophy  of,  625 
sarcoma  of,  628,  632 

wandering,  627 

(see  Fibromyoma) 
Fibroma  of  labia,  207 

of  ovary,  207 
Fibromyoma,  causes  of,  625 

classification  of,   627 

curetment   in,    639 

degeneration  of,    628 

diagnosis  of,  634 

diffuse,  628 

electricity  in,  638 

ergot  in,  637 

gangrene  of,   629 

infection  of,  629 

interstitial,  625 

intrallgamentary,   627 

intramural,   625 

of  uterus,    625 

operation  for,  641 

palliative  treatment  of,  637 

retroperitoneal,    627 

submucous,  627 

subperitoneal,  626 

subserous,   626 

suppuration   of,   629 

symptoms  of,   631 

treatment  of,  637 
Fibromyomata,  multiple,   626 
Finger-cots,  100 
Fingers,    examining,    40 
Fissure,  anal,  48 
Fistula,   506 

classification   of,   506 

denudation  in,  514 

fecal,   506 

recto-perineal,  506 

recto-vaginal,   506 

uretero-vaginal,  510 

vagino-rectal,  506 

vagino-vesical,  510 

vesico-vaginal,   510 
Fixation  of  uterus,  606,  675 

ventral,   610 
Fixing  specimens,  107 
Flap-splitting  operation,  499 
Flatus  vaginalis,  477 
Flexion  of  uterus,  599 
Floor,  pelvic,  468 
Fluid,   encysted,   128 
Follicles,  Graafian,  802 
Follicular  cysts,  810 

degeneration  of  cervix,  558 

erosions,   540 

vulvitis,  180,  405 


1008 


INDEX 


Folliculi,  hydrops,  810 
Foot-rests,    adjustable,   98 
Forceps,   artery,    481 

Crossen's  puncturing  tenaculum,  615 

dilating,  88,  572 

dissecting,   481 

hemostatic,  481 

sponge,  481 

tenaculum,  552 

tissue,  481 

uterine,   572 

vaginal,  572 
Foreign  bodies  in  abdomen,  925,  979 

in  vagina,   336 

in  uterus,   882 
Form,  female,  2 
Formal,  107 
Formulae,  987 

for  cathartics,    987 

for  emmenagogues,  987 

for  internal  use,  987 

for  local  use,  989 

for  ointments,  989 

for  powders,  990 

for  purgatives,  987 

for  sedatives,  987 

for  solutions,  990 

for  stimulants,  988 

for  suppositories,  991 

for  styptics,  988 

for  tablets,  991 

for  tonics,  989 

gynecologic,  987 
Fourchette,  376 

Function,  testing,  of  kidney,  912 
Functional  disturbances,  847 
Fungous  endometritis,  569 
Furbringer's  method,  916 


G 

Gall-bladder,  130,  146 
Gangrene  of  fibromyoma,  629 

of  vulva,  407 
Gangrenous  vulvitis,  407 
Garrulty  of  vulva,  477 
Gartner,  canal  of,  838 

duct  of,  838 
Gas  in  intestines,  126 
Gauze  drainage,  958 

in  drainage,  958 

iodoform,  716 

packing,  325 

strip  sponges,  929 

tampons,  325 
Gehrung  pessary,  343 
General  anesthesia,  91,  917 

debility,  111 

diseases,  110 

investigation,  11 

peritonitis,  717 
Genitalia,  375 
Genitals,  external,  375 

blood  vessels  of,  379,  380 

diseases  of,  384  (see  Diseases) 


Genitals,  external — Cont'd 

examination    of,    31,    170     (see    Examina- 
tion) 
Gestation,    ectopic,    764     (see    Extra-uterine 
pregnancy) 
extra-uterine,  764 
in  septate  uterus,  844 
in  uterine  horn,  271 
normal,  241,  250 
tubal,  764 
Gilliam-Crossen  operation,   612 
Gilliam-Ferguson  operation,  611 
Gilliam  operation,  611 
Gland  duct,  vulvo-vaginal,  35 
Glands,  Bartholin's,  abscess  of,  201,  441 
anatomy  of,  35,  379 
examination  of,  35 
palpation  of,  37 
lymphatic,  534 
of  cervix,  529 
of  endometrium,  528 
Skene's,  378,  399 
infection  of,  37,  399 
of  urethra,  378 
vulvo-vaginal,  35,  379 
abscess  of,  441 
anatomy  of,  35,  379 
carcinoma  of,  206 
cysts  of,  443 
discharge  from,  36 
examination  of,  44 
gonorrhoea  of,  398 
infection  of,  35,  441 
inflammation  of,  441 
palpation  of,  37 
Glandular  endometritis,  583 
Glass  drainage  tube,  954 

tube  in  drainage,  954 
Gloves,  boiling,  105,  914 
in  examination,  40 
rubber,  40    (see  Rubber  gloves) 
Glycerine,  104 

Gonococci,  bacteriologic  examination  for,  388 
Gonococcus,  389 
Gonorrhoea,  384 
cause  of,  384 
chronic,  398 
diagnosis  of,  387 
diplococcus  of,  389 
in  children,   401 
latent,  385 

of  external  genitals,  384 
of  Fallopian  tubes,  681 
of  vulvo-vaginal  gland,  398 
of  uterus,  562,  567 
symptoms  of,  386 
treatment  of,  393 
Gonorrhoeal  endocervicitis,  543 
endometritis,   502 
maculae,   55 
salpingitis,  746,  749 
urethritis,  384 
vaginitis,  384 
vulvitis,  384 
Graafian  follicles,  800 
Gram's  method,  391 


INDEX 


1009 


Graves'  speculum,  78 

Gynecologic  diagnosis,    118    (see   Diagnosis) 

abdomen    iu,  119 

baci--='che  in,  302 

chapter  on,   118 

cervix  uteri  in,  231,  291 

corpus  uteri  in,  238 

methods  of,  118 

pain  in  pelvis  in,  297 

pelvic  mass  in,  256 

table  for,  287 

vaginal,  234 

vulvar,  170 
disease,  relation  of  insanity  to,  759 
examination,   13 

abdominal,    14    (see   Examination) 

bacteriologic,  384,  387 

bimanual,  52,  238 

chapter  on,  1 

digital,  39,  224 

history  in,  1 

instrumental,  77 

of  external   genitals,   31    (see   Examina- 
tion) 

of  virgin,  74 

order  of,  14 

palpation  of  coccyx  in,  77 

pelvic,  53 

physical,  14 

preparations  for,  98 

record  of,   11 

recto-vagino-abdominal,  75 

under  anesthesia,  91 

vaginal,  40  (see  Examination) 

vagino-abdominal,  52   (see  Examination) 

when  required,  13 
formulae,  987 
postures,  367 
pressure  treatment,  364 
records,  11 
therapy,  304 
treatment,  internal,  370 

intrauterine,   346    (see  Treatment) 
Gynecology,  x-ray  in,  345 

H 

Hand  brushes,  103 

sterilization  of,  103 

disinfection,  915 
methods  of,  916 

examining,  40 
Hands,  disinfection  of,  100,  915 

sterilization  of,  100,  915 
Hard-rubber  disk  pessaries,  340 
Harrington's  solution,  914 
Head  mirror,  82 
Heart  sounds,  fetal,  29 
Heat,  100,  307 
Hegar's  operation,  496 
Hematocele,  pelvic,  766 
Hematocolpos,  185 
Hematoma,   intraligamentary,  260 

of  broad  ligament,  260 

of  external  genitals,  454 

pelvic,  260 


Hematoma — Cont'd 

pudendal,  454  > 

subperitoneal,  769 

vulvar,  190 
Hematometra,  255 
Hematosalpinx,  786 
Hemoglobin,  112 
Hemorrhage  from  Fallopian  tube,  786,  794 

from  ovary,  794 

in  cervical  polypi,  562 

in  extra-uterine  pregnancy,  766 

in  fibroids,   631 

in  tubal  pregnancy,  766 

intraperitoneal,  766 

pelvic,  793 

post-operative,  960 

shock  from,  776 

subcutaneous,  454 

tampon  for,  325 

treatment  for,  791 

uterine,  179 

vulvar,  454,  457 
Hemorrhagic  endometritis,  569 
Hemostatic  forceps,  481 
Hermaphroditism,    845 
Hernia,  452 

abdominal,  124 

inguinal,  452 

inguino-labial,   452 

of  external  genitals,  452 

pudendal,  452 

umbilical,  122 

vaginal,  452 

ventral,   123 

vulvar,  452 
Herpes  of  external  genitals,  411 

of  vulva,  411 
Herpetic  vesicles,  411 
History  cards,  12 

in  examination,  1 

marriage  in  the,  6 

taking,  1 

judgment  in,  11 
Hodge  pessary,  328 
Holder,  leg,  573 
Home,  operation  in,  911 
Horizontal  posture,  15 
Hospital,  operation  in,  911 
Hot  rectal  irrigation,  359 

vaginal  douche,  316 

water  bag,  308 
Hottentot  apron,  203 
Hydatid   cyst,   593 

disease,  593 

mole,   594 
Hydatidiform  mole,   594 
Hydrocele  of  external  genitals,  454 
Hydronephrosis,   262 
Hydrops  folliculi,   810 
Hydrosalpinx,  278,  730,  735 
Hydrotherapy,  365 
Hydro-ureter,  262 
Hymen,  38,  171 

absence  of,  977 

anatomy  of,  170 

anomalies  of,  171 


1010 


INDEX 


Hymen — Cont'd 

atresia  of,  184,  185 

development  of,   840 

imperforate,  185 

malformation  of,  184 

rudimentary,  977 
Hyperesthesia   of   external    genitals,    464 
Hyperplasia  of  endometrium,  583 
Hypertrophic  endometritis,  584 
Hypertrophy   of  cervix  uteri,   560 

of  clitoris,  204 

of  labia,  203,  448 

stasis,  191,  448 
operation  for,   451 

supravaginal,   220 
Hypodermoclysis,  960 
Hypogastric  region,  21 
Hypospadias,   840 
Hysterectomy,  abdominal,   641,  677 

partial,  947 

supravaginal,   641 

total,  641 

vaginal,  641 

varieties  of,  641 
Hysteria,  116 
Hysterorrhaphy,    610 


Ice  bag,  310 
Ichthyol,  322 
Ileus,  962 

Iliac  thrombosis,  963 
Illumination,  82 
Imperforate  hymen,  185 
diagnosis   of,  185,  842 
illustration  of,  184 
symptoms  of,  842,  853 
treatment  of,  842 
Impotency,   894 
Incision,    919 
abdominal,  919 
care,  922 
closure,  922 
dressing,  922 
removing  sutures,  951 
strapping,  951 
suturing,  922 
cervical,  closure  of,  554 
for  cervix  repair,  553 
for  pelvic  floor  repair,  483,  496,  500 
Emmet's,  489 
Hegar's,  497 
Tait's,  301 
perineal,  closure  of,  490 
suprapubic,  919 
Incomplete  abortion,  8 
Incontinence  of  urine,  519 
Indecent  assault,  969 

Indications   for   abdominal   section,   752,    910 
(see  Abdominal  section) 
for  conservative  surgery,  946 
for  knee-chest  posture,  369 
for  nutritive   enemata,   725 
for  operation,   910 
for  repair  of  cervix,  551 


Indications — Cont'd 

for  repair  of  pelvic  floor,  479 
Induration,  vesical,  266 
Infant,  endometrium  of^  525 
Infantile  uterus,  521 
Infected  endometritis,  562,  567 
Infection,   698,   717 

localized,  705 

of  abdominal  wound,  962 

of  cervical  wound,  557 

of  cervix  uteri,  542 

of  corpus  uteri,   562 

of  Fallopian  tubes,   699 

of  fibromyoma,  629 

of  lymphatics,   664 

of  ovarian  tumor,  830 

of  ovaries,  699,  730,  734 

of  peritoneum,  715 

of  Skene's   glands,   37,   399 

of  urethra,  397 

of  uterus,   562 

of  vagina,  387,  413 

of  veins,  700 

of  vulva,   402 

of  vulvo-vaginal   glands,  441 

puerperal,  715 
Inflammation,  384,  698 

acute    pelvic,    698     (see    Acute    pelvic    in- 
flammation) 

chronic  pelvic,  728    (see  Chronic  pelvic  in- 
flammation) 

leucocytosis  in,  115 

of  endometrium,   562 

of  external  genitals,  36,  180 

of  Fallopian  tubes,  699 

of  ovary,  730 

of  pelvic  connective  tissue,  699,  734 

of  urethra,  397,  438 

of  uterus,  562 

of  vagina,  413,  417 

of  vulva,  402 

of  vulvo-vaginal  gland,  441 

opiates  in,  704 

pelvic,  141 
prophylaxis    of,    698 

purgatives  in,  704 

rest  in,  306,  704 

retrodisplacement  with  acute,  606 
with  chronic,  607 
Inflated  ring  pessaries,  340 
Infusion,  intravenous,  960 
Inguinal  adenitis,  425 

hernia,  452 
Inguino-labial  hernia,  452 
Injections,   intrauterine,   562 

intravenous,   960 

rectal,  48,  73,  358 

vaginal,  311 

subcutaneous,  960 

submucous  paraflSn,  344 
Injuries  from  labor,  473,  547 

of  bladder,  925 

of  cervix,  547 

of  external  genitals,  457 

of  intestines,  925 

of  ureter,  925 


< 


INDEX 


1011 


Injuries — Cont'd 

of  uterus,  547 

of  vulva,  457 
Insanity  from  disease,  759 

post-operative,  759 

relation  of,  to  gynecologic  disease,  759 
Inspection  of  abdomen,  15,  119 

of  cervix  uteri,  82,  291 

of  external  genitals,   31,  170 

of  pelvic  cavity,  921 

of  vaginal  walls,  81 

of  vulva,  31,  170 
Instrument  sterilizer,  101 
Instrumental    examination,    77    (see    Exami- 
nation) 

by  curet,  90,  95 

by  excision,   86 

by  Sims'  speculum,  84 

by  sound,  87 

by  speculum,  77 
Instrumentation,  intrauterine,  87 
Instruments,  boiling,  100 

for  curetment,  572 

for  repair  of  cervix,  552 

for  repair  of  pelvic  floor,  481 

sterilization  of,  101 
Internal  use,  formulae  for,  987 
Interstitial  endometritis,  568 

extra-uterine  pregnancy,  251 

fibroids,  626 

fibromyoma,  625 

pregnancy,  251,  770 
Intertrigo,  410 

of  external  genitals,  410 
Intestinal  distention,  126 

movement,  134 

obstruction,  962 

paralysis,  961 

tenderness,  139 

tympany,  126 
Intestines,  adhesions  of,  731,  736 

diseases  of,  281 

gas  in,  126 

injuries  of,  925 
Intraligamentary  cyst,  260 

fibroid,  627 

fibromyoma,   627 

hematoma,  260 
Intramural  fibromyoma,   625 
Intraperitoneal  hemorrhage,   766 
Intrauterine  applications,  346 

douche,  351 

examination,  asepsis  in,   100 

exploration,   87 

injections,  349 

instrumentation,  87 

treatment,   346    (see   Treatment) 
Intravenous  infusion,  960 

injections,  960 
Introduction  of  pessary,  333 
Inversion  of  uterus,  228 
Investigation,  general,  11 
Iodoform  gauze,  716 
Irrigation,  hot  rectal,  359 

of  uterine   cavity,  351 

of  vagina,  311 


Irritable  uterus,   589 
Ischio-rectal  abscess,  257 
Ischuria,  961 
Isthmic  pregnancy,  765 


Judgment  in  diagnosis,    118 
in  examination,  117 
in  explanation  to  patients,  758 
in  history  taking,  11 
in  operations,    909 
in  palliative  treatment,  714 
in  prognosis,  758 

K 

Kelly's  pad,  substitute  for,  98 
Kidney,  139 

diseases   of,  280 

displacement  of,  274 

examination   of,   274 

movable,   139 

pain  in,  10 

palpation  of,  274 

tenderness  of,  25 

testing  function  of,  912 

tumor  of,  167 

percussion   of  abdomen    in,   166 

wandering,  274 
Knee-chest  posture,  367 

description  of,  367 

in  examination,  72 

in  gynecologic  treatment,  367 

in  pelvic  tumor,  369 

in  prolapse,  369 

in  puerperium,  369 

in  retrodisplacement,  604 

indications  for,  369 
Kobelt's  tubules,  809 
Kraurosis  vulvae,  458 

causes  of,  458 

diagnosis  of,  458 

pathology  of,  458 

prognosis  of,   460 

symptoms  of,  458 

treatment  of,  459 

x-ray  in,  459 


Labia,  170,   375 

adhesions  of,   185 

diseases  of,  182,  384 

elephantiasis  of,  196,  449 

fibroma  of,  207 

hypertrophy  of,  203 

majora,  375 

malformation   of,   184,  466 

minora,  376 

adherent,  184,  466 

stasis  hypertrophy  of,  448 

structure  of,   375 
Labor,  injuries  from,  473,  547 
Lacerated    cervix,    Emmet's    operation    for, 
551 


1012 


INDEX 


Lacerated — Cont'd 

pelvic  floor,  Emmet's  operation  for,  482 
Lacerations,  186,  473 
of  cervix,  292,  547 
causes,  547 
complications,  549 
diagnosis,   549 
examination,    550 
operation,  551 
pathologic  changes,  547 
prognosis,   557 
symptoms,  549 
treatment,  551 
varieties,   547 
of  external  genitals,  186 
of  pelvic  floor,  186,  473 
causes,    473 
diagnosis,  44,  186 
Emmet's  operation,  482 
Hegar's  operation,  496 
pathology,   474 
symptoms,  476 
Tait's  operation,  499 
treatment,  478 
of  perineum,  186 
of  vulva,  186 
Lamp,  examination  by,  82 
Laparotomy,  909    (see  Abdominal  section) 
Lassar's  paste,   990 
Latent  gonorrhoea,  385 
Lateral  regions,   palpation   of,   58 
Lavage,   720 
Laxative  enemata,   961 
Left  hand  in  examination,  69 

lateral  posture,  85 
Leg  holders,  573 
Leucocytosis,  113 
in  diagnosis,  114 
in  fever,  113 
in  inflammation,   114 
in  pain,    113 
Leucorrhoea,  32 
causes  of,  176 
in  children,  415 
significance  of,  176 
treatment  of,   903 
varieties  of,  32 
Levator  ani,   contraction  of,  42 
muscle,  470 
suturing  of,  487 
Life,  chaiige  of,  850 
Ligament,  broad,  535 
tumor  of,  276 
varicose  veins  of,  797 
round,  535 
anatomy,  535 
fibroids  of,  448    • 
myoma  of,  276 
operations  on,  609 
transplantation  of,  611 
tumor  of,  276 
sacro-uterine,  533 
vesico-uterine,  533 
Ligatures,  481,  552 
Lipoma  of  uterus,  658 
of  vulva,  448 


Liquid  soap,  103 
Lithopedion,  283 
Liver,  130 

diseases  of,  156 

enlarged,  percussion  of  abdomen  in,  156 
Local  anesthesia,  73,  322 
Local  use,  formulae  for,  989 
Localized  infection,  962 

pain,  5 

tenderness,  24 
Louse,  pubic,  412 
Lubricants,  103 
Lungs,  111 
Lupus  vulvae,  431 

x-ray  in,  433 
Lymphadenitis,  425 
Lymphangitis,  406 
Lymphatic  glands,  534 
Lymphatics,  infection  of,  699,  752 

of  uterus,  533 

of  vagina,  383 

of  vulva,  381 
Lysol,  990 

M 

Maculae,  gonorrhoeal,  387 
Malaria,  113 
Malformations,  836 
congenital,  184,  836 
of  bladder,  132 
of  cervix,  255 
of  clitoris,  184,  204 
of  external  genitals,  184 
of  Fallopian  tubes,  765,  841 
of  hymen,  184 
of  labia,  184,  466 
of  ovary,  841 
of  urethra,  840 
of  uterus,  844 

absence,  854 

bicornis,   838,   844 

didelphys,  841 

double,  841 

duplex,  841 

fetal,  872 

infantile,  872 

rudimentary,  844 

septate,  840 

unicornis,  841 
of  vagina,  186,  843 
of  vulva,  184,  434 
Malignant  degeneration,  633 
disease  of  cervix  uteri,  659 

of  corpus  uteri,  686 

of  external  genitals,  434 

of  Fallopian  tubes,  796 

of  ovaries,  832 

of  uterus,  659 

of  vagina,  435 

of  vulva,  434 
Malposition  of  uterus,  239 
Marriage  as  cause  of  disease,  385    • 
contraindications  to,  385 
in  the  history,  6 
sterility  in,  895 


INDEX 


1013 


Married,  dysmenorrhoea  in  the,  889 
Mass  in  abdomen,  2(),  148   (see  Abdomen) 
Massage  in  gynecologic  treatment,  359 

pelvic,  359 
Masturbation,  376 

Materials  for  nutritive  enemata,  725 
Measurements,  30 
Melancholia,  116 
Membranes,  fetal,  96 
Membranous  dysmenorrhoea,  873 
Menge  pessary,  341 
Menopause,  528 

bleeding  in,  851 

definition  of,  850 

diagnosis  of,  850 

duration  of,  850 

metrorrhagia  in,  851 

physical  changes  in,  528 

symptoms  of,  850 

synonyms   of,    850 

time  for,  850 

treatment  of,  851 
Menorrhagia,  863 

causes  of,  863 

diagnosis  of,  863 

pathologic  significance  of,  863 

symptoms  of,  863 

treatment  of,  865 
Menses,  suppression  of,  862 
Menstruation,  528,  672 

definition  of,  847 

delayed,  890 

diagnosis  of,  849 

disorders  of,  847 
amenorrhoea,  851 
delayed   menstruation,  890 
dysmenorrhoea,   867 
menorrhagia,  863 
precocious  menstruation,  891 
retarded  menstruation,  890 
vicarious  menstruation,  891 

duration  of,  849 

endometrium   at,   528 

physical  changes  in,  528 

physiologic   significance  of,   850 

precocious,   891 

relation  of  puberty  to,  848 

retarded,  890 

symptoms  in,  849 

synonyms   of,   849 

time  for,  848 

treatment  of,  850 

vicarious,  891 
Mensuration  of  abdomen,  30 
Mesenteric  cyst,  133 
Metastasis,  666 
Method,  Apostoli,   638 

Fiirbringer's,   916 

Gram's.  391 
Methods  in  gynecologic  treatment,  304 

non-gynecologic    examination,    110 

of  diagnosis,  118   (see  Diagnosis) 

of  examination,  13 

of  hand  disinfection,  916 

of  replacement,  603 
Metritis,  589 


Metritis — Cont'd 

acute,   566 

atrophic,   585 

chronic,  567 
Metrorrhagia,  179 

causes  of,  904 

definition  of,  869 

diagnosis  of,  904 

from  abortion,  90,  905 

from  cancer,   670 

from  fibroid,   631 

from  polyp,  562 

from  tubal  pregnancy,  773 

in  menopause,  851 

symptoms  of,   867,   904 

treatment  of,   906 
Microscopic    examination    of    curetting,    96, 
670 

of  excised  tissue,  97   ■ 

of  pus,  35,  388 
Microcysts,  810 
Mirror,  head,  82 
Moist  heat  in  gynecologic  treatment,  307 

warts,   444 
Mole,  hydatid,   594 
Morgagni.  cyst  of,   809 
Movable  kidney,  139 

retrodisplacement,   63 
Movement,  intestinal,  134 

fetal,  27 

of  abdomen,  134 

of  wall,  134 
Mucosa,   cervical,   epithelium  of,   529 
eversion  of,  .548 

urethral,  prolapse  of,  211,  439 
Muller,  duct  of,  836 
Multilocular  ovarian  cyst,  820 
Multiple  condylomata,  444 

fibromyomata,    626 
Muscle,  levator  ani,  470 
Muscles,  recti,  124 
separation  of,  124 

transverse  perineal,  469 
Mycotic  vaginitis,  415 
Myoma,  cervical,  628 

of  round  ligament,  276 

of  uterus,  625 
Myomectomy,    641 

abdominal,  641 
Myometrium,  525 
Myxomatous  degeneration,  628 

N 

Nausea,  960 
Necrobiosis,  628 
Necrosis.   629 
Needle    holder,    481,    552 

Sims',    481 
Needles,  481,   552 
Neoplasms  of  Fallopian  tubes,  796 

of  ovaries,  799 

of  uterus,  226,  244,  626 

of  vagina,  435,  448 

of  vulva.  434,  448 
Nephritis,  111 


1014 


INDEX 


Nephroptosis,   273 

Nerve  trunks,  69 

Nerves,  pelvic,  69 

Nervous  system,  examination  of,  116 

Neuralgia,  69 

Neurasthenia,  116 

Neuromata  of  vulva,  464 

Neuroses,  116,  139 

Nodule  in  cervix,  236 

Noma  of  vulva,  407 

Non-gynecologic  examination  methods,  110 

Normal  gestation,  241,  250 

Nuck,  canal  of,  452 

Nurse,  99 

Nutritive  enemata,  725 

directions  for  giving,  725 

indications  for,  725 

materials  for,  725 
Nymphae,  170,  376 
Nymphomania,  464 

O 

Obesity,  120 

abdomen  in,  25,  27,  121 
Obstruction,  intestinal,  962 

of  bowels,  962 

to  coitus,  892 
Occlusion  of  cervix,  255 

of  Fallopian  tubes,  729 

of  vagina,  842 
Office  arrangements,  99 

assistant  in,  99 
Oidium  albicans,  415 
Ointment,  Crede's,  349 
Ointments,  formulae  for,  989 
Omental  cysts,  129 
Oophorectomy,  757,  831 
Oophoritis,  699,  738 

suppurative,  699,  730 
Operation,  abdominal,  909 

Alexander's,  609 

anesthesia  for,  917 

asepsis  in,  913  (see  Asepsis) 

assistant  in,  915 

bowels  after,  495 
before,  913 

cervix,  denudation  in,  554 

technique  of,  553   (see  Technique) 

complications  of,  954 

conservative,  in  salpingitis,  945 
on  Fallopian  tubes,  945 

contraindications  for,  910 

Crossen's,  retrodisplacement,  615 

cystocele,  technique  of,  505 

Dudley's,  for  dysmenorrhoea,  885    - 

Emmet's,  for  lacerated  cervix,  551 
for  lacerated  pelvic  floor,  482 

ether  for,  917 

flap-splitting,  499 

for  anteflexion  of  cervix,  885 

for  cancer  of  uterus,  677 

for  displacement,  classification  of,  609 

for  fibromyoma,  641 

for  prolapse,  623 

for  retrodisplacement,  609 


Operation — Cont'd 

for  stasis  hypertrophy,  451 

Gilliam,  611 

Gilliam-Ferguson,  611 

Hegar's,  496 

in  gynecologic  treatment,  373 

in  home,  911 

in  hospital,  911 

indications  for,  910 

in  salpingitis,   714,  744 

judgment  in,  745 

on  round  ligament,  609 

opiates  after,  948 

pelvic  floor,  denudation  in,  484 

technique   of,    482,    496,    499    (see   Tech- 
nique) 

plastic,  480,  551 

Porro,  657 

preparation  for,  911 

prognosis  in,  958 

purgatives  after,  950,  961 
before,  913 

rest  after,  952 

Schroeder's,  on  cervix  uteri,  557 

vaginal,  942 

vomiting  after,  960 

water  after,  949 
before,  912 

Wertheim's,  678 
Operator,  face  mask  for,  915 
Opiates  after  operation,  948 

in  inflammation,  704 
Order  of  examination,  13 
Organs,  pelvic,  1,  3 
Orgasm,  sexual,  894 
Os,  pin-hole,  896 
Outlet,  vaginal,  470 
Ovariotomy,  831 
Ovarian  abscess,  699,  730 

cysts,  810 

multilocular,  820 

thrombosis,  700 

tumors,  799 

infection  of,  830 

percussion  of  abdomen  in,  157,  165 
Ovaries,  799 

accessory,  841 

adhesions  of,  736 

anatomy  of,  799 

anomalies  of,  841 

blood  vessels  of,  539 

cancer  of,  832 

carcinoma  of,  832 

cirrhosis  of,  739 

conservative  surgery  of,  945 

cystadenoma  of,  812 

cystic  degeneration  of,  810 

cystoma  of,  812 

dermoid  of,  821 

development  of,  801 

diseases  of,   679,    718,    730,    799    (see   Dis- 
eases) 

displacement  of,  736,  740 

examination  of,  60 

extract  of,  807 

fibroma  of,  207 


INDEX 


1015 


Ovaries — Cont'd 

hemorrhage  from,  786 
infection  of,  699,  730 
inflammation  of,  699 
malformation  of,  841 
malignant  disease  of,  832 
neoplasms  of.  810,  832 
palpation  of,  60 
papilloma  of,  819 
prolapse  of,  740 
removal  of,  888 
resection  of,  946 
rudimentary,  841 
sarcoma  of,  832 
serous  cyst  of,  816 
solid  tumor  of,  832- 
supernumerary,  841 
tuberculosis  of,  760 
tumor  of,  810 
vessels  of,  532 

Ovaritis,  699 

Oviducts,  4,  521,  691 

Ovulation,  803 

Ovum,  805 

Oxalic  acid,  916 

Oxygen,  988 


Packing,  325 

gauze,  325 

vaginal,  325 
Pad,  Kelly's,  substitute  for,  98 
Pads  and  sponges,  914,  929 
Pain,  297 

in  coitus,  892 

in  extra-uterine  pregnancy,  773 

in  kidney,  10 

in  pelvis    in    gynecologic    diagnosis, 
(see  Diagnosis) 

leucocytosis  in,  113 

localized,  24 
Palliative  treatment,  judgment  in,  714 

treatment  of  fibromyoma,  637 
Palpation,  abdominal,  15,  137 

bimanual,  52,  238 

digital,  39,  224 

of  abdomen,  15,  135 

of  Bartholin's  glands,  37 

of  coccyx,  77 

of  Fallopian  tubes,  61 

of  kidneys,  274 

of  lateral  regions,  58 

of  ovaries,  60 

of  ureters,  68 

of  uterus,  53,  238 

of  vulvo-vaginal  gland,  37 

recto-abdominal,  73 

recto-vagino-abdominal,  75 

vaginal,   39 

vagino-abdominal,  52,  238 
Pancreatic  cysts,  133 
Panhysterectomy,  641 
Papillary  cyst,  816 
causes  of,  818 
description  of,  817 


297 


Papillary  cyst — Cont'd 
diagnosis  of,  819 
pathology   of,  818 
prognosis  of,  821 
symptoms  of,  821 
treatment  of,  823 
erosion,  539 
Papilloma  of  Fallopian  tube,  796 

of  ovary,  821 
Paquelin   cautery,    345 
Paraffin  injection,  submucous.  344 
Paralysis  from  anesthesia,  918 

intestinal,  961 
Parametrium,   677 
Parasites,  vulvar,  412 
Paroophoron,   809 
Parovarian  cyst,  832 
Parovarium,  809 

anatomy  of,  809 
Partial  amputation  of  cervix  uteri,  557 

hysterectomy,  947 
Parturition,  473,  547 
Paste,  Lassar's,  990 

Pathologic  significance  of  menorrhagia,  863 
Pathology  of  endometritis,  562,  567 
of  kraurosis  vulvae,  458 
of  papillary  cysts,  818 
of  peritonitis,  715 
of  pruritis  vulvae,  460 
of  salpingitis,  699,  729 
of  tubal  pregnancy,   765    (see  Tubal  preg- 
nancy) 
Patients,  judgment  in  explanation  to,  758 
Pediculated  fibroid,  626 
Pediculosis  of  external  genitals,   412 
Pediculus  pubis,  412 

Pelvic  abscess,   260,   691,  706    (see  Abscess) 
after-treatment  in,  713 
bacteria   in,   746 
drainage   in,   710 
affections,   bowels   in.   743 
anatomy,  1,  520,  691 
cavity,  inspection  of,  921 
cellulitis,  699,  734 
connective    tissue,    inflammation    of.    699, 

734 
examination,  52,  91 
exudates,   699,   730 
floor,  44,  468 
anatomy  of,  467 
blood  vessels  of,  469 
examination  of,  44 

Emmet's  operation  for  lacerated,   482 
incision  for  repair  of,  489,  501   (see  In- 
cision) 
instruments  for,  481 
lacerations  of.  473   (see  Lacerations) 
operation,    technique    of,    482,    496,    499 

(see  Technique) 
operations,  denudations  in,  484 
repair,    incision    for,    489,    501    (see    In- 
cision) 
repair  of,  482.  499   (see  Repair) 
suturing  of,  489,  497 
tears  of,  473 


1016 


INDEX 


Pelvic — Cont'd 

gynecologic    examination,    14 

hematocele,    766 

hematom-,  260 

hemorrhage,  793 

inflammation,  141 

acute,    698    (see  Acute   pelvic   inflamma- 
tion) 
chronic,  728    (see  Chronic  pelvic  inflam- 
mation) 
prophylaxis  of,  698 

mass    in    gynecologic    diagnosis,    148    (see 
Diagnosis) 

massage,   359 

nerves,  69 

organs,  1,  3 

peritonitis,   715 

suppuration,   705 

tumor,   625,  659 

knee-chest  posture  in,  369 
Pelvis,  antero-posterior  section  of,  1,  3 

congestion  of,  864 

echinococcus  disease  of,  798 

pain  in,  in  gynecologic  diagnosis,  297 

pus  in,  699,  730 

tenderness  in,  63 

tuberculosis   of,    760 
Percussion  of  abdomen,  28,  156 

deep,  30 

in  ascites,  157 

in  distended  bladder,  154 

in  kidney  tumor,   166 

in  enlarged  liver,  156 

in  enlarged  spleen,  156 

in  enlarged  uterus,  154 

in  ovarian  tumor,  157,  165 

in  retroperitoneal  tumor,  166 

in  uterine  tumor,   165 

superficial,  30 
Pericaecal  abscess,  291 
Perineal  incision,  closure  of,   490 
Perineorrhaphy,   482,   501    (see  Pelvic  floor) 

after-treatment  in,    493 

preparations   for,    480 
Perineum,  39,  467 

lacerations  of,  186    (see  Lacerations) 

suturing  of,  489,   502 
Perirenal  tumor,  169 
Peritoneal  drainage,  716,  954 
Peritoneum,   535 

anatomy  of,  535 

diseases  of,  283 

infection  of,  715 

inflammation  of,  716 

toilet  of,  921 

tuberculosis  of,  764 
Peritonitis,  715 

bacteria  in,  698 

causes  of,  698 

diagnosis  of,  702 

drainage   in,   716 

general,  717 

pathology  of,  717 

pelvic,  715 
-symptoms  of,  717 

treatment   of,   717 


Peritonitis — Cont'd 

tubercnlar,  761 
Perityphlitis,   271 
Periurethral  abscess^  438 
Pessaries,   328 

action  of,  329 

care  of,  336 

cup  and  belt,  342 

for  cystocele,  342  --' 

for  prolapse,  340 

for  retrodisplacement,  328 

hard-rubber  disk,  340 

Hodge,  328 

Gehrung,  343 

in  gynecologic  treatment,  328 

inflated  ring,  340 

introduction  of,  333 

Menge,  341 

Skene,  343 

Smith,  328 

Thomas,  328 

varieties  of,  328 
Phagedenic  chancroid,  425 
Phlebitis,  700,  763 
Phlegmasia  dolens,  763 
Phlegmonous  vulvae,  406 
Physical  change  in  menopause,  528 
in  menstruation,  528 

examination,  13 
Physiologic  significance  of  menstruation,  850 
Pincus,  atmocausis  of,  353 
Pin-hole  os,  896 
Pitcher  douche,  494,  965 
Placental  remnants,  97 
Plaster,  adhesive,  951 
Plastic  operation,  480,  551 
Points,    special,    in    abdominal    section,    923 

(see  Abdominal   section) 
Polyp,  metrorrhagia  from,  562 
Polypi,  237,  562 

cervical,   562 

hemorrhage  in,  562 

of  cervix  uteri,  562 
Polypoid  endometritis,  569 
Porro  operation,  657 
Portio  vaginalis,  525 
Position  of  arms  during  anesthesia,  917 

of  uterus,  595 
Posterior  displacements,  597 
Post-operative  adhesions,  962 

enemata,  961 

hemorrhage,  960 

insanity,  759 

vomiting,   960 

tympanites,  961 
Posture,  dorsal,  31 

erect,  1,  2 

gynecologic,  367 

horizontal,  15 

knee-chest,  367 
description  of,  367 
in  examination,  72 
in  gynecologic  treatmeBt,  367 
in  pelvic  tumor,   3€9 
in  prolapse,  369 
in  puerperium,  369 


INDEX 


1017 


Posture — Cont'd 

knee-chest 

in  retrodisplacement,  604 
indications  for,  369 

left  lateral,  85 

semi-prone,  83 

Sims.   83,  85 

Trendelenburg,  570 
Powders,  formulae  for,  990 
Precocious  menstruation,  891 
Pregnancy,  130,  241,  249 

abdomen  in,  130,  242,  251,  254 

ampullar,   766 

auscultation  in,  29 

diagnosis  of,  240 

extra-uterine,    704,    764    (see   Extra-uterine 
pregnancy) 

in  uterine  horn,  271 

interstitial,  251,  766 

isthmic,  766 

tubal,  764 

hemorrhage  in,  766 

pathology  of,  765  (see  Tubal  pregnancy) 

wandering,  771 
Pre-operative  enemata,  913 
Preparations  for  abdominal  section,  753,  911 
(see  Abdominal  section) 

for  anesthesia,  111 

for  curetment,  571 

for  examination,  98 

for  operation,  911 

for  perineorrhaphy,  480 

for  repair  of  cervix,  551 

for  repair  of  pelvic  floor,  480 

for  trachelorrhaphy,  551 

for  vaginal  section,  944 

of  operator,  915 
Prepuce,  adherent,  184,  185,  466 
Preservation  of  specimens,  10,  107 
Proctoclysis,  722 
Prognosis  in  operation,  758 

judgment  in,  758 

of  kraurosis  vulvae,  460 

of  papillary  cysts,  821 

of  salpingitis,  727,  758 
Prolapse,  knee-chest  posture  in,  369 

of  bladder,  191,  217 

of  ovary,  740 

of  urethral  mucosa,  211,  439 

of  uterus,  211 
causes,  619 
diagnosis,  621 
pathology,  619 
radical  treatment,  623 
symptoms,  620 
treatment,  622 

of  vagina,  189 

operation  for,  623 

pessaries  for,  340 

vaginal,  217,  504 
Proliferating  cysts,  812 
Prominence  of  abdomen,  120,  180 
Prophylaxis  of  endometritis,  563 

of  pelvic  inflammation,  698 

of  retrodisplacement,  597 

of  shock,  92l 

of  subinvolution,  588 


Prurigo  of  vulva,  411 
Pruritus  vulvae,  460 

causes  of,  460 

diagnosis  of,  461 

pathology  of,  460 

symptoms  of,  461 

treatment  of,  461 

x-ray  in,  464 
Pseudo-hermaphroditism,    845 
Pseudomucinous  cysts,  813 
Psychoses,  116 
Puberty,  848 

relation  of,  to  menstruation,  848 
Pubic  louse,  412 
Pudendal  hematoma,  454 

hernia,  452 

hydrocele,  454 

tumor,  448 
Puerperal  abscess,  bacteria  in,  751 

infection,    562,   698 
Puerperium,  knee-chest  posture  in,  369 
Purgatives  after  operation,  950,  961 

before  operation,  915 

formulae  for,  987 

in  inflammation,  704,  743 
Purulent  discharge,  32 
Pus  in  pelvis,  705,  744 

microscopic  examination  of,  35,  388 
Putting  on  rubber  gloves,  104 
Pyaemia,  bacteria  in,  746 
Pyometra,  255 
Pyosalpinx,  276,   277,  691 

bacteria  in,  748 

Q 

Quadrants,  20 

Questions,   diagnostic  table  of,   287 
in  fibroid  cases,  636 


R 

Radical  treatment  for  cancer  of  uterus,  673 

for  fibroid  of  uterus,  641 

for   prolapse   of  uterus,    623 

for  salpingitis,  714,  744 
Rape,  969 

of  children,   971 
Reasons  for  conservative  surgery,  946 
Rectal  applications,  358 

digital  examination,  73 

examination,    48,    73 

injections,  48,  73,  358 

irrigation,  hot,  359 

touch,  73 

treatment,  306 
Recti  muscles,  124 

separation  of,  124 
Records,  11 

diagrams  in,  11 

gynecologic,  11 

of  examination,   11 
Recto-abdominal  examination,  73 
Recto-abdominal   palpation,   73 
Rectocele.  189,  193,  504 
Recto-perineal  fistula,   506 


1018 


INDEX 


Recto-vaginal  fistula,  506 
Recto-vaglno-abdominal    examination,    75 
Rectum,  48 

carcinoma  of,  664 

examination  of,  48 
Regeneration  of  endometrium,  581 
Region,  epigastric,  21 

hypogastric,  21 

umbilical,   23 
Regions  of  abdomen,  18,  23,  135 
Regular    steps    in    abdominal    section,    760, 

916   (see  Abdominal  section) 
Relaxed   abdominal   wall,   124    (see   Abdomi- 
nal   V'cill) 

vaginal  outlet,  44 
Remnants,  decidual,   97 

placental,  97 
Removal  of  ovary,  888,  946 

of  sutures,  951 
Renal  tumor,  167 
Repair  of  cervix,  551 

after-treatment  for,   556 
denudation  for,   554 
incisions  for,    553 
indications  for,   551 
instruments  for,  552 
preparations  for^   551 
steps  in,  553 
sutures  in,  554 
of  pelvic  floor,  482,  489 
after-treatment  for,  493 
denudation  for,   484,   497,  502 
flap-splitting    operation    for,    409 
incisions  for,  484,  496,  500 
indications  for,  479 
instruments  for,  481 
preparations  for,  480 
steps  in,  483 

Emmet's   operation,  482 
Hegar's  operation,  496 
other  operations,  504 
Tait's  operation,  499 
sutures  in,  490,  497,  502 
Replacement,  bimanual,  603 
methods  of,  603 
of  uterus,  603 
of  Fallopian  tubes,  946 
Resection  of  vaginal  outlet,  482 

of  ovaries,  946 
Resonance,   corona  of,   157 
Rest,  306 

after  operation,  952 
in  gynecologic   treatment,   306 
in  inflammation,  306 
Retarded  menstruation,  851 
Retention  cysts,  558 
of  blood,   185 
of  urine,  130 
Retractors,  vaginal,  481 
Retrodisplacement,  adherent,  606 
cases,  classification  of,  614 
causes  of,  597 
definition  of,  597 
diagno^s  of,  601 
knee-chest  posture  in,  604 
movable,  603 


Retrodisplacement — Cont'd 

of  uterus,  597 

operation  for,  609 

pessaries  for,  328 

prophylaxis   of,   597 

replacement   of,    603 

retroversion,  599 

symptoms  of,  600 

treatment  of,  603 

with   acute   infiammation,   606 

with   chronic    inflammation,    607 
Retroflexion,  599 
Retroperitoneal  fibromyoma,  627 

tumor,   166 

percussion  of  abdomen  in,   166 
Retroposition  of  uterus,  239 
Retroversion,  599 
Retroversio-flexion,    597 
Retroverted  uterus,   239 
Right  lower  abdomen,  23,  135 
Rodent  ulcer,   436 
Round  ligament,  535 

anatomy  of,  535 

fibroids  of,  448 

myoma  of,  276 

operations  on,  609 

transplantation  of,  611 

tumor  of,    276 
Routine  use  of  rubber  gloves,  104 
Rubber  dam,   954 

drains,    710,   958 

gloves,  102,  104 

in  abdominal  section,  755,  916   (see  Ab- 
dominal section) 
in  examination,  104 
putting  on,  104 
routine  use  of,  104 
sterilization  of,  104 

tube  drainage,  710,  958 
Rudimentary  Fallopian  tubes,  765 

hymen,  977 

ovaries,  841 

uterus,  844 

vagina,  843 

vulva,  840 
Rupture  of  bladder,  130 

of  Fallopian  tubes,  766 


Sacro-uterine  ligaments,  533 
Sactosalpinx,  276 
Saline  solution,  722 
Salpingectomy,  744 
Salpingitis.  699,  729 

acute,  699 

bacteria  in,  698 

causes  of,  698 

chronic,  729 

conservative  operation  in,  945 

diagnosis  of,  701,  732 

gonorrhoeal,   746 

operation  in,  744 

pathology  of,  699,  729 

prognosis  of,  727,  757 

radical  treatment  for,  744 


INDEX 


lOliJ 


Salpingitis — Cont'd 
suppurative,  (lOO,  729 
symptoms  of,  701,  732 
treatment  of,  704,  743 
tubercular,  7G2 
varieties  of,  099,  729 
Salpingo-oophorectomy,  744 
Sarcoma  of  ovary,  832 
of  uterine  fibroids,  628 
of  uterus,  689 
of  vagina,  436 
of  vulva,   434 
Scabies,  413 

Schroeder's  operation  on  cervix  uteri,  557 
Scopolamin  in  anesthesia,  793 
Section,  1,  3 
abdominal,  909 

after-treatment   of,    948    (see  Abdominal 

section) 
bandage  in,  763,  951 
contraindications  for,   752,   910 
dressings  after,  771,  951,  954 
dressings  in,  761,  922 
drainage  in,  764,  954 
exploratory,  675,  944 
indications  for.  752,  910 
position  of  arms  during,  917 
preparations  for,  752,   753,  911    (see  Ab- 
dominal section) 
regular  steps   in,   760,   916    (see  Abdom- 
inal section) 
rubber  gloves  in,  755,  916 
special  steps  in,  760,  923  (see  Abdominal 
section) 
antero-postsrior,  of  pelvis,  1,  3 
Caesarean,  659 
exploratory  vaginal,  943 
vaginal,  942 

after-treatment  in,  965 
preparations  for,  944 
Sedatives,  formulae  for,  987 
Semi-prone  posture,  83 
Senile  bleeding,  851 

endometrium,  526,  528,  563 
vaginitis,  417 
vulvitis,  417,  460 
Separation   of   recti   muscles,    124    (see    Ab- 
dominal wall) 
Sepsis,  715 
Septate  utei-us,  840 
gestation  in,  844 
Septic  endometritis,  562 
Serous  cyst  of  ovary,  816 
Sexual  disturbances,  892 

orgasm,  894 
Shape  of  abdomen,  15,  120 

of  abdomen  in  ascites,  126,  128 
Shock,  924,  959 
causes  of,  924 

from  extra-uterine  pregnancy,  776 
from  hemorrhage,  776 
prophylaxis  of,  924 
symptoms  of,  776 
treatment  of,  959 
Significance  of  leucorrhoea,  176 
of  menorrhagia,  863 


Significance — Cont'd 

of  menstruation,  850 
Signs  of  ascites,  126 

of  extra-uterine  pregnancy,  773 
Silkworm-gut,  481 
Silver  wire,  514 
Simple  endometritis,  566,  583 

ulcer,  419 

vaginitis,  413 

vulvitis,  402 
Sims'  needle-holder,  481 

posture,  83,    85 

speculum,  83,   84 
Sinus,  964 
Sitz-bath,  308 
Skene  pessary,  343 
Skene's  glands,  378,  399 

infection  of,   399 

of  urethra,  378 
Smith  pessary,  328 
Soap,  103 

in  examination,  103 

liquid,   103 
Soft  chancre,  421 
Solid  tumor  of  ovary,  832 

of  vulva,  434,  448 

of  uterus,  626,  659 
Solution,  Harrington's,  914 

saline,  722,  988 
Solutions,   formulae   for,   990 
Sound,  instrumental  examination  by,  87 

uterine,  88 
Special    points    in    abdominal    section,    760, 

923   (see  Abdominal  section) 
Specimens,  fixing,  107 

from  examination,  107 

preservation  of,  10,  107 
Speculum,  83 

bivalve,   78 

cylindrical,    83 

Edebohl's,    572 

examination  by,  77,  84 

Graves',  78 

Sims',  84 
Sphincter  ani,   493 

suturing  of,  493 
Spleen,  130 

diseases  of,  156 

enlarged,   percussion   of  abdomen   in,   156 
Split-tube  drainage,  958 
Sponge  forceps,  481 
Sponges,   929 

abdominal,    929    (see    Abdominal    section) 

Crossen's  gauze-strip,  929 

detached,  934 
Sputum,  examination  of,  115 
Standing  posture,  examination  in,  50 
Stasis  hypertrophy,  191,  448 

of  vulva,  448 

operation  for,  451 
Stenosis  of  cervix,  544 

of  vagina,  842 
Steps  in  curetment,  572 

in   repair  of  cervix,   553 

in  repair  of  pelvic  floor,  482,  496,  499  (see 
Repair) 


1020 


INDEX 


Sterility,  895 
causes  of,  895 
treatment  of,  898 
Sterilization  of  abdomen,  913 

of  abdominal  dressing,  914 
of  abdominal   surface,   754,    913    (see   Ab- 
dominal section) 

of  catheters,  966 

of  hand  brushes,  103 

of  hands,  100,  915 

of  rubber  gloves,  104 

of  sutures,  914 

of  instruments,  101 

of  vulva,  480 
Sterilizer,  instrument,  101 
Stimulants,   959 

formulae  for,  988 
Stitch-hole  abscess,  962 
Stomach,  acute  dilatation  of,  961 
Structure  of  labia,  375 
Stupes,  turpentine,  307 
Styptics,  formulae  for,  988 
Subcutaneous  hemorrhage,  454 

injections,  960 
Subinvolution  of  uterus,  587 

prophylaxis  of,  588 
Submucous  fibromyoma,  627 

paraffin   injection,  344 
Subperitoneal  fibroid,   625,  626 

hematoma,   769 
Subserous   fibromyoma,   626 
Substitute  for  Kelly's  pad,  98 
Suburethral  abscess,  212 
Superficial  percussion  of  abdomen,  30 
Superinvolution    of  uterus,   589 
Supernumerary  ovary,  841 
Supporter,    abdominal,    733,    951     (see    Ab- 
dominal section) 

uterine,    342 
Supports  of  uterus,  596 
Suppositories,    formulae    for,    991 
Suppression  of  menses,  862 
Suppuration  of  abdominal  wound,  962 
diagnosis   of,   962 
symptoms  of,  962 
treatment  of,  962 

of  fibromyoma,  629 

pelvic,  706 
Suppurative  oophoritis,   699,  730 

salpingitis,   699,    730 
Suprapubic   incision,   919 
Supravaginal  amputation,  641 

hypertrophy,  220 

hysterectomy,  641 
Surface,  abdominal,  sterilization  of,  913  (see 

Abdominal  section) 
Surgery,  conservative,  757   (see  Conservative 

surgery) 
Suspension,  ventral,  610 
Sutures,  buried,  497,  502 

catgut,  481 

continuous,  488,  491 

crown,  489,  491 

in  abdominal  wound,  922,  951 

in  cervix,  352,  555 

in  perineum,  489,  502 


Sutures — Cont'd 

in  repair  of  cervix,  554 

in  repair  of  pelvic  floor,  490,  498,  502 

removal  of,  951 

sterilization  of,  914 
Suturing  of  levator  ani,  487 

of  pelvic  floor,  489,  497,  502 

of   sphincter  ani,   493 

of  uterus  forward,  609 

of  vulva,  451 
Swelling  of  external  genitals,  38,  189 

of  vulva,  189 
Symptoms  in  menstruation,  849 

of  amenorrhoea,   851 

of  endometritis,  564,  569 

of  extra-uterine  pregnancy,  773 

of  flbromyoma,    631 

of  gonorrhoea,  386 

of  imperforate  hymen,  842 

of  kraurosis  vulvae,  458 

of  menopause,  850 

of  menorrhagia,  863 

of  metrorrhagia,   867,   904 

of  papillary  cysts,  819 

of  peritonitis,    715 

of  pruritis  vulvae,  461 

of  retrodisplacement,    600 

of  salpingitis,  701,  732 

of  shock,  776 

of  suppuration   of   abdominal   wound,   962 

of  tubal  pregnancy,  773 

of  vulvitis,  403 
Synonyms  of  menstruation,  849 

of  tubal  pregnancy,  764 
Syncytioma  malignum,  688 
Syphilides  of  vulva,  199,  430 
Syphilis,  427 

of  external  genitals,  427 


Table,  diagnostic,  of  questions,  287 

examining,  98 

for  gynecologic  diagnosis,  287 
Tablets,  formulae  for,  991 

vaginal,  991 
Taking  history,  1 
Tampons,  325 

for  hemorrhage,  325 

gauze,  325 

vaginal,  325 
T-bandage,  325 
Tears  of  pelvic  floor,  473 
Technique,  aseptic,  915 

of  cervix  operations,  553 
partial  amputation,  557 
regular  amputation,  561 

of  curetment,  572 

of  cystocele  operation,  505 

of  excision  of  vulva,  451 

of  pelvic  floor  operation,   482,  496,  499 
Emmet's,  483,  492 
Hegar's,   496 
Talt's,  499 
Tenaculum-forceps,  552 

Crossen's  puncturing,  615 


INDEX 


1021 


Tenderness  in  abdomen,  24,  137 
in  pelvis,  73 
intestinal,  139 
localized,   24 
of  kidney,  25 
urethral,  397 
I        vesical,  63 
Tension  of  abdomen,  15,  135 
Tents  for  dilating,  90 
Testing  function  of  kidney,  912 
Therapeutic  curetment,  571 

measures,  classification  of,  304 
Therapy,  gynecologic,  304 
Thomas  pessary,  328 
Thrombophlebitis,  700 

bacteria  in,  701 
Thrombosis,  broad  ligament,  700 
iliac,  701,  963 
ovarian,  701 
uterine,  701 
Thrush  of  vagina,  415 
Time  for  menopause,  850 
for  menstruation,   848 
Tissue  forceps,  481 
Toilet  of  peritoneum,  921 
Tonics,  formulae  for,  989 
Total  hysterectomy,  641 

Touch,    abdominal,    15    (see    Abdominal   sec- 
tion) 
educated,  67 
rectal,  73 
vaginal,  39 
Towels,  boiling,  914 
Trachelorrhaphy,  551 
after-treatment  in,  556 
preparations  for,  551 
Transplantation  of  round  ligament,   611 
Transverse  perineal  muscles,  469 
Traumatism  of  vulva,  457 
Treatment,  constitutional,  852 
for  hemorrhage,  960 
for  menopause,  851 
gynecologic,  304 
bathing  in,  365 
cold  in,  309 

counter-irritation  in,  310 
dress  in,  366 
dry  heat  in,  308 
intrauterine,  346 

applications,  319,  346 
cauterization,  352 
curetment,  352 
dilatation,  358 
electricity,  353 
irrigation,  351 
vacuum,  358 
knee-chest  posture  in,  367 
massage  in,  359 
methods  in,  304 
moist  heat  in,  307 
operations  in,  373 
pessaries  in,  328 
pressure  treatment  in,  364 
rest  in,  306 

vaginal  applications  in,  319 
vaginal  douches  in,  311 


Treatment — Cont'd 
internal,  370 
methods  of,  304 
of  amenorrhoea,  854,  861 
of  bloody   discharge,   906 
of  cystocele,  504 
of  dysmenorrhoea,    876,    889 
of  endometritis,   565,   570 
of  eversion  of  cervical  mucosa^  551 
of  extra-uterine  pregnancy,  790 
of  fibromyoma,  637 
of  gonorrhoea,  393 
of  imperforate  hymen,  842 
of  kraurosis  vulvae,  459 
of  leucorrhoea,  903 
of  menorrhagia,   854 
of  menstruation,  850 
of  papillary   cysts,   831 
of  peritonitis,  717 
of  pruritis  vulvae,  460 
of  retrodisplacement,    603 
of  salpingitis,   704,   743 
of  shock,  959 
of  sterility,   898 

of  suppuration  of  abdominal  wound,  962 
of  tubal  pregnancy,   790    (see  Tubal   preg- 
nancy) 
of  urethral  caruncle,  441 
of  vulvitis,  402 
palliative,  judgment  in,  744 

of  fibromyoma,  637 
rectal   gynecologic,   306 
vaginal,  319 
Trendelenburg   posture,    570 
Trials,  criminal,  986 
Trunks,  nerve,  69 
Tubal  abortion,  768 
abscess,  277,  699,  730 
gestation,  764 
pregnancy,  764 
causes  of,  764 
diagnosis  of,  772 
hemorrhage  in,  766 
metrorrhagia  from,  773 
pathology  of.  765 
carried  to  term,  772 
free  intraperitoneal  hemorrhage.  767 
hematocele,   766 
hematoma,  769 

mass  from  repeated  hemorrhage,  766 
tubal  abortion,  768 
symptoms  of,  772 
treatment  of,  790 
advanced   cases,  793 
before  rupture,  790 
moderate  hemorrhage,  791 
pelvic  hematocele,  790 
pelvic  hematoma,  793 
profuse  hemorrhage,  791 
varieties  of,  766 
Tubercular  adhesions,  762 
endometritis,  592 
peritonitis,  761 
salpingitis,  762 
vaginitis,   433 
Tuberculosis,  curetment  in,  592 


1022 


INDEX 


Tuberculosis — Cont'd 
of  endometrium,   592 
of  Fallopian  tubes,  761 
of  ovaries,  761 
of  pelvis,  761 
of  peritoneum,  761 
of  uterus,  592 
of  vagina,  433 
of  vulva,  431 
x-ray  in,  433 
Tubes,  blood  vessels  of,  693 
Fallopian,  691 
glass  drainage,  954 
Tubules,  Kobelt's,  809 
Tumor,  abdomen  in,  131,  148 
fibroid,  infection  of,  628 
kidney,  percussion  of  abdomen  in,  166 
of  abdomen,   132 
of  abdominal    wall,    121     (see    Abdominal 

wall) 
of  broad  ligament,  276 
of  external  genitals,  434,  448 
of  Fallopian  tube,  796 
of  kidney,  167 
of  ovary,  810 
of  round  ligament,  276 
of  uterus,  626,  659 
of  vagina,  435,  448 
of  vulva,  434,  448 
ovarian,  810 

infection  of,  830 

percussion  of  abdomen  in,  157,  165 
pelvic,  625,  659 

knee-chest  posture  in,   369 
perineal,  169 
pudendal,  448 
renal,  167 
retroperitoneal,  166 

percussion  of  abdomen  in,  166 
solid,  of  ovary,  832 

of  uterus,  626,   659 

of  vulva,   434,   448 
uterine,  625,  659 

percussion  of  abdomen  in,  165 
vesical,  132 
Turpentine  stupes,  307 
Two  fingers  in  examination,  70 
Tympanites,   126 
abdomen  in,  126 
in  examination,  28,  126 
post-operative,  961 
Tympany,  intestinal,   126 

U 

Ulcers,  37,  181,  419 

of  cervix  uteri,   541 

of  external  genitals,  37,  181,  419 

of  vagina,  419 

of  vulva,  181,  419 

rodent,  436 

simple,   419 
Ulcus  rodens,  436 

x-ray  in,  438 
Umbilical  hernia,  122 

region,  23,  152 


Unicornuate  uterus,  841 
Ureter,  139 
calculi  of,  259 
diseases  of,  259 
examination  of,  68 
injuries  of,  929 
palpation  of,  68 
Uretero-vaginal  fistula,  510 
Urethra,  378 
anatomy  of,  378 
anomalies  of,  840 
carcinoma  of,  434 
caruncle  of,  440 
diverticulum  of,  213 
diseases  of,  384   (see  Diseases) 
examination  of,   44 
infection  of,  438 
infiammation  of,  438 
malformation  of,  841 
Skene's  glands  of,  378 
Urethral  abscess,  438 
caruncle,  440 
discharge,  33 
diseases,  35 

mucosa,  prolapse  of,  211,  439 
tenderness,  41 
Urethritis,  35,  384,  399 
acute,  397 
bacteria  in,  33 
chronic,   399 
gonorrhoeal,  397,  399 
Urethrocele,  212 
Urinalysis,  111 
Urine,  examination  of.  111 
incontinence  of,  519 
retention  of,  130 
Uteri,  corpus,  568 
Uterine  cavity,  521 
irrigation  of,  351 
curet,  88,  572 
digital  examination,  96 
dilators,  88,  572 
diseases,  176 
fibroids,  atrophy  of,  625 

sarcoma  of,  628 
forceps,  572 
hemorrhage,  179 
horn,  gestation  in,  271 

pregnancy  in,  271 
sound,  88 
supporter,  342 
thrombosis,  700 
tumors,  625,  659 

percussion  of  abdomen  in,  154,  157,  165 
Uterus,  absence  of,  854 
adhesions  of,  606 
anatomy  of,  520 
anomalies  of,  844 
atresia  of,  255 
atrophy  of,  589 
bacteria  in,  562 
bicornuate,  841 
bimanual  examination  of,  53 
blood  vessels  of,  531 
cancer  of,  245,  294,  659 
radical  treatment  for,  673 


INDEX 


1023 


Uterus — Cont'd 
carcinoma  of,  659 
cirrhosis  of,  589 
congestion  of,  566 
conservative  surgery  of,  947 
development  of,  838 
diseases  of,  238,  537    (see  Diseases) 
displacement  of,  239,  595 
double,  840 

echinococcus  disease  of,  593 
enlarged,  percussion  of  abdomen  in,  154 
examination  of,  53 
fetal,  522 

fibroid  of,  radical  treatment  for,  641 
fibromyoma  of,  625  (see  Fibromyoma) 
fixation  of,  606,  675 
flexion  of,  599 
foreign  bodies  in,   882 
forward,  suturing  of,  609 
gonorrhoea  of,  562,  567 
infantile,  521,  522 
infection  of,  562 
inflammation  of,  562 
injuries  of,  547 
inversion  of,  228 
irritable,  589 
lipoma  of,  658 
lymphatics  of,  533 

malformation  of,   844    (see  Malformation) 
malignant  disease  of,   659    (see  Malignant 

disease) 
malposition  of,  239 
myoma  of,  625,  626 
neoplasms  of,  226,  244,  626 
operation  for  cancer  of,  677 
palpation  of,  53,  238 
position  of,  595 
prolapse  of,   211    (see  Prolapse  of  uterus) 

radical  treatment  for,  623 
replacement  of,  603 
retrodisplacement  of,  597 
retroposition  of,  239 
retroverted,  239 
rudimentary,  844 
sarcoma  of,  689 
septate,  840 

gestation  in,  844 
solid  tumor  of,  626,  659 
subinvolution  of,  587 
superinvolution  of,  589 
supports  of,  596 

tuberculosis  of,  592   (see  Tuberculosis) 
tumor  of,  626,  659 
unicornuate,  841 


Vagina,  1,  3 
absence  of,  185 
anatomy  of,  381 
anomalies  of,  840 
aphthae  of,  415 
atresia  of,  185 
bacteria  in,  388,  413 


Vagina — Cont'd 

blood  vessels  of,  383 
carcinoma  of,  435 
congenital  atresia  of,  185 
congestion  of,  81 
development  of,  837 
digital  examination  of,  39 
diseases  of,  224,  384    (see  Diseases) 
disinfection  of,  480,  575 
displacements   of,   217 
double,  185 

epithelioma  of,   289,  435 
epithelium   of,    383 
examination  of,  39,  79 
foreign  bodies  in,  336 
infection  of,  384,  413 
inflammation  of,  384,  413 
irrigation  of,  311 
lymphatics  of,  383 
malignant  disease  of,   435 
malformation  of,  186,  840 
neoplasms  of,  435,  448 
occlusion  of,  842 
prolapse  of,   189 
rudimentary,  840 
sarcoma  of,   436 
stenosis  of,  842 
thrush  of,  415 
tuberculosis   of,   433 
tumors  of,  435,  448 
ulcers  of,  419 
Vaginal  antisepsis,   575 

applications,  311    (see  Applications) 

cyst,  223 

diagnosis,  244,  289 

digital  examination,   39,   224 

diseases,  176 

douche,  hot,  316 

in  gynecologic  treatment,  311 
drainage,  710,  716 
examination,  39,  224   (see  Examination) 

asepsis  in,  100 
flatus,  477 
forceps,  572 
hernia,  452 
hysterectomy,  641 
injections,  311 
operation,   942 
orifice,  dilatation  of,  31,  465 
outlet,  470 

relaxed,    44 

resection  of,   482 
packing,    325 
palpation,  39 
prolapse,  217,   504 
retractors,  481 
section,  942 

after-treatment  in,    965 

anterior,  942 

exploratory,  766,  943 

preparations  for,  944 
tablets,  991 
tampons,  325 
touch,  39 
treatment,  318 


1024 


INDEX 


Vaginal — Cont'd 
walls,  42 

adhesions  of,  417 
inspection  of,  80 
Vaginalis,  portio,  525 
Vaginismus,  464 
Vaginitis,  acute,  413,  417 
adhesive,  417 
bacteria  in,  385,  413 
causes  of,  385,  413 
chronic,  398,  417 
diagnosis  of,  387,  414 
diphtheritic,  416 
emphysematous,   417 
gonorrhoeal,  384 
in  children,  415 
mycotic,  415 
senile,  417 
simple,  413 
tubercular,  433 
varieties  of,  384 
Vagino-abdominal   examination,  52    (see  Ex- 
amination) 
hysterectomy,  641 
Vagino-rectal  fistula,  506 
Vagino-vesical  fistula,  510 
Varicose  veins,  197,  456 
of  broad  ligament,  270 
of  external  genitals,  456 
of  vulva,   197,   456 
Varieties  of  diseases,  32,  176 
of  dysmenorrhoea,  868,  871 
of  endometritis,  538 
of  hysterectomy,  641 
of  leucorrhoea,  32 
of  pessaries,  328 
of  salpingitis,   699,   729 
of  tubal  pregnancy,  766 
of  vaginitis,  384 
of  vulvitis,   384 
Varix  of  vulva,  197,  456 
Vegetations  of  vulva,  198,  444 
Veins,  calculi  of,  797 
infection  of,  700 
varicose,  197,  456 
Venereal  diseases,  384,  421,  427 
Ventral   fixation,   610 
hernia,  123 
suspension,  610 
Vermiform  appendix,  272 
Verruca,  444 
Vesical  induration,  266 
tenderness,  41 
tumor,    266 
Vesicles,  herpetic,  411 
Vesico-uterine  ligament,   533 
Vesico-vaginal  fistulae,  510 
Vessels  of  ovary,  532 
Vestibule,  75,  170,  377 

bulbs  of,  279 
Vicarious  menstruation,  891 
Violence  in  coitus,  189 
Virgin,  amenorrhoea  in  the,  852 
dysmenorrhoea  in  the,  870 
examination  of,  74 


Virgin — Cont'd 

gynecologic  examination  of,  13 
Virus,  chancroidal,  421 
Vomiting,  960 

after  operation,  960 
Vulva,  32,  170 

anatomy  of,   170,  375 
atresia  of,  184 
blood  supply  of,  380 

vessels  of,  381 
carcinoma  of,  183,  434 
chancroid  of,  181 
condylomata  of,  198,  444 
contusion  of,  457 
diseases  of,  170   (see  Diseases) 
disinfection  of,  480 
epithelioma  of,  183,  205,  434 
epithelium  of,  377 
erysipelas  of,  405 
examination  of,  31 
excision  of,  451 
extirpation  of,  451 
gangrene  of,  407 
garrulty  of,  477 
herpes  of,  411 
infection  of,  384,  402 
inflammation  of,  384,  402 
injuries  of,  457 
inspection  of,  31,  170 
lacerations  of,  186  (see  Lacerations) 
lipoma  of,  448 
lymphatics  of,   381 
malformations  of,  184,  434 
malignant  disease  of,  434 
neoplasms  of,  434,  448 

neuromata  of,  464 

noma  of,  407 

phlegmon  of,  406 

prurigo  of,  411 

rudimentary,  840 

sarcoma  of,  434 

solid  tumor  of,  434,  448 

stasis  hypertrophy  of,  448 

sterilization  of,  480 

suturing  of,  451 

swelling  of,  189 

syphilides  of,  199,  430 

technique  of  excision  of,  451 

traumatism  of,  457 

tuberculosis  of,  431 

tumor  of,  434,  448 

ulcer  of,  181,  419 

varicose  veins  of,  456 

varix  of,  197,  456 

vegetations  of,  198,  444 

wounds  of,   457 

kraurosis   of,   458 
x-ray  in,  459 

lupus  of,  431 

pruritis  of,  460 
x-ray  in,  464 

ulcus  rodens  of,  436 
Vulvar  applications,  321 

cellulitis,   406 

dermatitis,  402 


INDKX 


1025 


Vulvar — Cont'd 

diagnosis,    31,   170    (see  Diagnosis) 
diseases,  176,  402    (see  Diseases) 

classification  of,  384 
dressings,  580 
eczema,   408 
enterocele,  452 
hernia,  452 
hematoma.  190 
hemorrhage,  454,  457 
itching,   460 
jiarasites.  412 
Vulvitis,  402 
acute,  384,  402 
causes  of,  384,  402 
chronic,  401,  405 
diagnosis  of,  403 
follicular,  ISO,  405 
gangrenous,  407 
gonorrhoea!,  384 
senile,  417,  460 
simple,  402 
symptoms  of,  403 
treatment  of,  403 
varieties  of,  384 
Vulvo-vaginal  abscess,  441 
cvst,  443 
gland,  35,  379 

abscess  of,  441 

anatomy  of,  35,  379 

carcinoma  of,  206 

cysts  of,  443 

discharge  from,  36 

duct,  35 

examination  of,  44 

infection  of,  37,  441 

inflammation  of,  441 

gonorrhoea  of,  398 

palpation  of,  37 


W 

Waist  constriction,  SCO 

Wall,    abdominal,    16,    120     (see    Abdominal 
wall) 

movement  of,  134 

vaginal,  42 
Wandering  fibroid,  G27 

kidney,  274 

pregnancy,  771 
Warm  applications,  307 
Warts,  44 

excision  of,  445 

moist,  444 
Water  after  operation,  949 

bag,  hot,  308 

before  operation,  912 
Wave  in  ascites,  27 
Wertheim's  operation,  678 
Wire,  silver,  514 
Wolffian  body,  809,  836 

duct,   836 
Wound,     abdominal,     919      (see     Abdominal 
wound) 
infection  of,  962 
suppuration  of,  962 
sutures  in,  922,   951 

cervical,  infection  of,  557 

of  vulva,  457 

X 

X-ray  in  cancer,  345,  685 
in  gynecology,  345 
in  Ivraurosis  vulvae,  459 
in  lupus  vulvae,  433 
in  pruritis   vulvae,  464 
in  tuberculosis,  433 
In  ulcus  rodens,  438 


